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As the mitogen-activated protein kinase (MAPK) signalling pathway is activated in many paediatric cancers, it is an important therapeutic target. Currently, a range of targeted MAPK pathway inhibitors are being developed in adults. However, MAPK signals through many cascades and feedback loops and perturbing the MAPK pathway may have substantial influence on other pathways as well as normal development. In view of these issues, the ninth Paediatric Strategy Forum focused on MAPK inhibitors.Development of MAPK pathway inhibitors to date has been predominantly driven by adult indications such as malignant melanoma. However, these inhibitors may also target unmet needs in paediatric low-grade gliomas, high-grade gliomas, Langerhans cell histiocytosis, juve-nile myelomonocytic leukaemia and several other paediatric conditions. Although MAPK in-hibitors have demonstrated activity in paediatric cancer, the response rates and duration of responses needs improvement and better documentation. The rapid development and evalua-tion of combination approaches, based on a deep understanding of biology, is required to optimise responses and to avoid paradoxical tumour growth and other unintended conse-quences including severe toxicity. Better inhibitors with higher central nervous systempenetra-tion for primary brain tumours and cancers with a propensity for central nervous system metastases need to be studied to determine if they are more effective than agents currently be-ing used, and the optimum duration of therapy with MAPK inhibition needs to be determined.Systematic and coordinated clinical investigations to inform future treatment strategies with MAPK inhibitors, rather than use outside of clinical trials, are needed to fully assess the risks and benefits of these single agents and combination strategies in both front-line and in the re-fractory/relapse settings. Platform trials could address the investigation of multiple similar products and combinations. Accelerating the introduction of MAPK inhibitors into front-line paediatric studies is a priority, as is ensuring that these studies generate data appropriate for scientific and regulatory purposes. Early discussions with regulators are crucial, particularly if external controls are considered as randomised control trials in small patient populations can be challenging. Functional end-points specific to the populations in which they are studied, such as visual acuity, motor and neuro psychological function are important, as these outcomes are often more reflective of benefit for lower grade tumours (such as paediatric low-grade glioma and plexiform neurofibroma) and should be included in initial study designs for paediatric low-grade glioma. Early prospective discussions and agreements with regulators are necessary.Long-term follow-up of patients receiving MAPK inhibitors is crucial in view of their pro-longed administration and the important involvement of this pathway in normal development.Further rational development, with a detailed understanding of biology of this class of products, is crucial to ensure they provide optimal benefit while minimising toxicity to children and adolescents with cancer.(c) 2022 Merck Sharp & Dohme LLC., a subsidiary Merck & Co., Inc., Rahway, NJ, USA and The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Additional file 1: Figure S1. Distribution of body weight in children, adolescents, and young adults receiving atezolizumab. Patients aged

TOPIC 1: Water molecules mediating polar interactions in ligand–protein complexes contribute to both binding affinity and specificity. To account for such water molecules in computer-aided drug discovery, we performed an extensive search in the Cambridge Structural Database (CSD) to identify the geometrical criteria defining interactions of water molecules with ligand and protein. In addition, ab initio calculations were used to derive the propensity of ligand hydration. Based on these information we developed an algorithm (AcquaAlta) to reproduce water molecules bridging polar interactions between ligand and protein moieties. This approach was validated using 20 crystal structures and yielded a match of 76% between experimental and calculated water positions. The solvation algorithm was then applied to the docking of oligopeptides to the periplasmic oligopeptide binding protein A (OppA), supported by a pharmacophore-based alignment tool. TOPIC 2: Drug metabolism, toxicity, and interaction profile are major issues in the drug discovery and lead optimization processes. The Cytochromes P450 (CYPs) 2D6 and 2C9 are enzymes involved in the oxidative metabolism of a majority of the marketed drugs. By identifying the binding mode using pharmacophore pre-alignement and automated flexible docking, and quantifying the binding affinity by multi-dimensional QSAR, we validated a model family of 56 compounds (46 training, 10 test) and 85 (68 training, 17 test) for CYP2D6 and CYP2C9, respectively. The correlation with the experimental data (cross- validated r2 = 0.811 for CYP2D6 and 0.687 for CYP2C9) suggests that our approach is suited for predicting the binding affinity of compounds towards the CYP2D6 and CYP2C9. The models were challenged by Y-scrambling, and by testing an external dataset of binding compounds (15 compounds for CYP2D6 and 40 for CYP2C9) and not binding compounds (64 compounds for CYP2D6 and 56 for CYP2C9). TOPIC 3: After injury, neurites from mammalian adult central nervous systems are inhibited to regenerate by inhibitory proteins such as the myelin-associated glycoprotein (MAG). The block of MAG with potent glycomimetic antagonists could be a fruitful approach to enhance axon regeneration. Libraries of MAG antagonists were derived and synthesized starting from the (general) sialic acid moiety. The binding data were rationalized by docking studies, molecular dynamics simulations and free energy perturbations on a homology model of MAG. The pharmacokinetic profile (i.e. stability in cerebrospinal fluid, logD, and blood-brain barrier permeation) of these compounds has been thoroughly investigated to evaluate the drug-likeness of the identified antagonists.

Techniques grounded on the simultaneous utilization of Tiecks' second order differential equations and spontaneous variability of mean arterial pressure (MAP) and mean cerebral blood flow velocity (MCBFV), recorded from middle cerebral arteries through a transcranial Doppler device, provide a characterization of cerebral autoregulation (CA) via the autoregulation index (ARI). These methods exploit two metrics for comparing the measured MCBFV series with the version predicted by Tiecks' model: normalized mean square prediction error (NMSPE) and normalized correlation rho. The aim of this study is to assess the two metrics for ARI computation in 13 healthy subjects (age: 27 & PLUSMN; 8 yrs., 5 males) at rest in supine position (REST) and during 60 head-up tilt (HUT) and in 19 patients (age: 64 & PLUSMN; 8 yrs., all males), scheduled for coronary artery bypass grafting, before (PRE) and after (POST) propofol general anesthesia induction. Analyses were carried out over the original MAP and MCBFV pairs and surrogate unmatched couples built individually via time-shifting procedure. We found that: i) NMSPE and rho metrics exhibited similar performances in passing individual surrogate test; ii) the two metrics could lead to different ARI estimates; iii) CA was not different during HUT or POST compared to baseline and this conclusion held regardless of the technique and metric for ARI estimation. Results suggest a limited impact of the sympathetic control on CA.

We present a framework for the linear parametric analysis of pairwise interactions in bivariate time series in the time and frequency domains, which allows the evaluation of total, causal and instantaneous interactions and connects time- and frequency-domain measures. The framework is applied to physiological time series to investigate the cerebrovascular regulation from the variability of mean cerebral blood flow velocity (CBFV) and mean arterial pressure (MAP), and the cardiovascular regulation from the variability of heart period (HP) and systolic arterial pressure (SAP). We analyze time series acquired at rest and during the early and late phase of head-up tilt in subjects developing orthostatic syncope in response to prolonged postural stress, and in healthy controls. The spectral measures of total, causal and instantaneous coupling between HP and SAP, and between MAP and CBFV, are averaged in the low-frequency band of the spectrum to focus on specific rhythms, and over all frequencies to get time-domain measures. The analysis of cardiovascular interactions indicates that postural stress induces baroreflex involvement, and its prolongation induces baroreflex dysregulation in syncope subjects. The analysis of cerebrovascular interactions indicates that the postural stress enhances the total coupling between MAP and CBFV, and challenges cerebral autoregulation in syncope subjects, while the strong sympathetic activation elicited by prolonged postural stress in healthy controls may determine an increased coupling from CBFV to MAP during late tilt. These results document that the combination of time-domain and spectral measures allows us to obtain an integrated view of cardiovascular and cerebrovascular regulation in healthy and diseased subjects.

Obstructive sleep apnea (OSA) is a sleep disorder characterized by breathing pauses due to collapse of the upper airways. During OSA the autonomic modulation, as noninvasively assessed through heart period (HP) variability, is altered in a time-varying way even though time-varying properties of HP fluctuations are often disregarded by HP variability studies. We performed a time domain analysis computed over very short epochs corresponding to the sole OSA events explicitly accounting for HP variability nonstationarities. Length-matched epochs were extracted during OSA and quiet sleep (SLEEP) in 13 subjects suffering from OSA (11 males, age 55±11, apnea-hypopnea index 44±19). Mean HP, variance and variance of the residual after exponential detrending were assessed as well as the parameters a and b of the exponential fitting in the form y(n)=a·exp(b·n). HP mean and the parameter a increased during OSA compared to SLEEP. The variance of the residual was significantly lower than original variance during both OSA and SLEEP, while the dispersion of the parameter b was significantly larger. Nonstationarities were evident during both SLEEP and OSA but more dramatically apparent during OSA, thus stressing the need of accounting for them when the autonomic control during OSA is under scrutiny.

Cardiovascular and cerebrovascular regulatory systems are vital control mechanisms responsible for guaranteeing homeostasis and are affected by respiration. This work proposes the investigation of cardiovascular and cerebrovascular control systems and the nonlinear influences of respiration on both regulations through joint symbolic analysis (JSA), conditioned or unconditioned on respiration. Interactions between cardiovascular and cerebrovascular regulatory systems were evaluated as well by performing correlation analysis between JSA indexes describing the two control systems. Heart period, systolic and mean arterial pressure, mean cerebral blood flow velocity and respiration were acquired on a beat-to-beat basis in 13 subjects experiencing recurrent syncope episodes (SYNC) and 13 healthy individuals (non-SYNC) in supine resting condition and during head-up tilt test at 60° (TILT). Results showed that JSA distinguished conditions and groups, whereas time domain parameters detected only the effect of TILT. Respiration affected cardiovascular and cerebrovascular regulatory systems in a nonlinear way and was able to modulate the interactions between the two control systems with different outcome in non-SYNC and SYNC groups, thus suggesting that the analysis of the impact of respiration on cardiovascular and cerebrovascular regulatory systems might improve our understanding of the mechanisms underpinning the development of postural-related syncope.