Inhaled drugs to reduce exacerbations in patients with chronic obstructive pulmonary disease: a network meta-analysis

BACKGROUND: Most patients with chronic obstructive pulmonary disease (COPD) receive inhaled long-acting bronchodilators and inhaled corticosteroids. Conventional meta-analyses established that these drugs reduce COPD exacerbations when separately compared with placebo. However, there are relatively few head-to-head comparisons and conventional meta-analyses focus on single comparisons rather than on a simultaneous analysis of competing drug regimens that would allow rank ordering of their effectiveness. Therefore we assessed, using a networkmeta analytic technique, the relative effectiveness of the common inhaled drug regimes used to reduce exacerbations in patients with COPD. METHODS: We conducted a systematic review and searched existing systematic reviews and electronic databases for randomized trials of >=4 weeks' duration that assessed the effectiveness of inhaled drug regimes on exacerbations in patients with stable COPD. We extracted participants and intervention characteristics from included trials and assessed their methodological quality. For each treatment group we registered the proportion of patients with >=1 exacerbation during follow-up. We used treatment-arm based logistic regression analysis to estimate the absolute and relative effects of inhaled drug treatments while preserving randomization within trials. RESULTS: We identified 35 trials enrolling 26,786 patients with COPD of whom 27% had >=1 exacerbation. All regimes reduced exacerbations statistically significantly compared with placebo (odds ratios ranging from 0.71 (95%confidence interval [CI] 0.64 to 0.80) for long-acting anticholinergics to 0.78 (95% CI 0.70 to 0.86) for inhaled corticosteroids). Compared with long-acting bronchodilators alone, combined treatment was not more effective (comparison with long-acting beta-agonists: odds ratio 0.93 [95% CI 0.84 to 1.04] and comparison with long-acting anticholinergics: odds ratio 1.02 [95% CI 0.90 to 1.16], respectively). If FEV1 was 40% predicted. This effect modification was significant for inhaled corticosteroids (P=0.02 for interaction) and combination treatment (P=0.01) but not for long-acting anticholinergics (P=0.46). A limitation of this analysis is its exclusive focus on exacerbations and lack of FEV1 data for individual patients. CONCLUSIONS: We found no evidence that one single inhaled drug regimen is more effective than another in reducing exacerbations. Inhaled corticosteroids when added to long-acting beta-agonists reduce exacerbations only in patients with COPD with FEV1<=40%

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology

Patient Safety in Internal Medicine

AbstractHospital Internal Medicine (IM) is the branch of medicine that deals with the diagnosis and non-surgical treatment of diseases, providing the comprehensive care in the office and in the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly. IM is a key ward for Health National Services. In Italy, for example, about 17.3% of acute patients are discharged from the IM departments. After the epidemiological transition to chronic/degenerative diseases, patients admitted to hospital are often poly-pathological and so requiring a global approach as in IM. As such transition was not associated—with rare exceptions—to hospital re-organization of beds and workforce, IM wards are often overcrowded, burdened by off-wards patients and subjected to high turnover and discharge pressure. All these factors contribute to amplify some traditional clinical risks for patients and health operators. The aim of our review is to describe several potential errors and their prevention strategies, which should be implemented by physicians, nurses, and other healthcare professionals working in IM wards

Nature and significance of small volume fall deposits at composite volcanoes: Insights from the October 14, 1974 Fuego eruption, Guatemala

The first of four successive pulses of the 1974 explosive eruption of Fuego volcano, Guatemala, produced a small volume (∼0.02 km3 DRE) basaltic sub-plinian tephra fall and flow deposit. Samples collected within 48 h after deposition over much of the dispersal area (7–80 km from the volcano) have been size analyzed down to 8 φ (4 µm). Tephra along the dispersal axis were all well-sorted (σ φ = 0.25–1.00), and sorting increased whereas thickness and median grain size decreased systematically downwind. Skewness varied from slightly positive near the vent to slightly negative in distal regions and is consistent with decoupling between coarse ejecta falling off the rising eruption column and fine ash falling off the windblown volcanic cloud advecting at the final level of rise. Less dense, vesicular coarse particles form a log normal sub-population when separated from the smaller (Mdφ < 3φ or < 0.125 mm), denser shard and crystal sub-population. A unimodal, relatively coarse (Mdφ = 0.58φ or 0.7 mm σ φ = 1.2) initial grain size population is estimated for the whole (fall and flow) deposit. Only a small part of the fine-grained, thin 1974 Fuego tephra deposit has survived erosion to the present day. The initial October 14 pulse, with an estimated column height of 15 km above sea level, was a primary cause of a detectable perturbation in the northern hemisphere stratospheric aerosol layer in late 1974 to early 1975. Such small, sulfur-rich, explosive eruptions may substantially contribute to the overall stratospheric sulfur budget, yet leave only transient deposits, which have little chance of survival even in the recent geologic record. The fraction of finest particles (Mdφ = 4–8φ or 4–63 µm) in the Fuego tephra makes up a separate but minor size mode in the size distribution of samples around the margin of the deposit. A previously undocumented bimodal–unimodal–bimodal change in grain size distribution across the dispersal axis at 20 km downwind from the vent is best accounted for as the result of fallout dispersal of ash from a higher subplinian column and a lower “co-pf” cloud resulting from pyroclastic flows. In addition, there is a degree of asymmetry in the documented grain-size fallout pattern which is attributed to vertically veering wind direction and changing windspeeds, especially across the tropopause. The distribution of fine particles (<8 µm diameter) in the tephra deposit is asymmetrical, mainly along the N edge, with a small enrichment along the S edge. This pattern has hazard significance

A comparative study of Brachychiton populneus seed and seed-fiber oils in Tunisia

We conducted a comparative study of two oils extracted from Brachychiton populneus seeds and seed fibers grown in Tunisia. Oil yields from seed and seed fiber were 29.95 and 5.30%, respectively. GC-MS analysis showed that the most abundant fatty acid was linoleic acid (37.91%) followed by oleic acid (30.67%) in seeds. In seed fiber, the most abundant were oleic acid (62.04%) and linoleic acid (11.90%). Sterculic acid (7.27%), a rare fatty acid, was detected in seed oil. Moreover, carotenoid and chlorophyll levels were approximately two-fold higher in seed-fiber oil (39.66 and 1.9 mg/kg) than in seed oil (19.48 and 0.78 mg/kg). Tocol contents were more than 10-fold higher in fiber-seed oil (979.31 mg/100 g) than in seed oil (83.2 mg/100 g). Furthermore, thermal behavior (TGA and DSC) in both oils, and the antioxidant activity, phenolic content, and oxidative stability at different temperatures in seed oil were evaluated. The results of this study suggest that B. populneus seed oil may have an important role in non-food applications and that seed-fiber oil is a source of high-value compounds