Combination formoterol and budesonide as maintenance and reliever therapy versus combination inhaler maintenance for chronic asthma in adults and children.

BACKGROUND: Asthma is characterised by chronic inflammation of the airways and recurrent exacerbations with wheezing, chest tightness and cough. Treatment with inhaled steroids and bronchodilators often results in good control of symptoms, prevention of further morbidity and mortality and improved quality of life. Several steroids and beta2-agonists (long- and short-acting) as well as combinations of these treatments are available in a single inhaler to be used once or twice a day, with a separate inhaler for relief of symptoms when needed (for patients in Step three or higher, according to Global Initiative for Asthma (GINA) guidelines). Budesonide/formoterol is also licenced for use as maintenance and reliever therapy from a single inhaler (SiT; sometimes referred to as SMART therapy). SiT can be prescribed at a lower dose than other combination therapy because of the additional steroid doses being received as reliever therapy. It has been suggested that using SiT improves compliance and hence reduces symptoms and exacerbations, but it is unclear whether it increases side effects associated with the use of inhaled steroids. OBJECTIVES: To assess the efficacy and safety of budesonide/formoterol in a single inhaler (SiT) to be used for both maintenance and reliever therapy in asthma in comparison with maintenance treatment provided through combination inhalers with a higher maintenance steroid dose (either fluticasone/salmeterol or budesonide/formoterol), along with additional fast-acting beta2-agonists for relief of symptoms. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register of trials, online trial registries and drug company websites. The most recent search was conducted in November 2013. SELECTION CRITERIA: We included parallel-group, randomised controlled trials of at least 12 weeks' duration. Studies were included if they compared single-inhaler therapy with budesonide/formoterol (SiT) versus combination inhalers at a higher maintenance dose of steroids than was given in the SiT arm (either salmeterol/fluticasone or budesonide/formoterol). DATA COLLECTION AND ANALYSIS: We used standard methods expected by The Cochrane Collaboration. Primary outcomes were exacerbations requiring hospitalisation, exacerbations requiring oral corticosteroids and serious adverse events (including mortality). MAIN RESULTS: Four studies randomly assigning 9130 people with asthma were included; two were six-month double-blind studies, and two were 12-month open-label studies. No trials included children younger than age 12. Trials included more women than men, with mean age ranging from 38 to 45, and mean baseline steroid dose (inhaled beclomethasone (BDP) equivalent) from 636 to 888 μg. Mean baseline forced expiratory volume in one second (FEV1) percentage predicted was between 70% and 73% in three of the trials, and 96% in another. All studies were funded by AstraZeneca and were generally free from methodological biases, although the two open-label studies were rated as having high risk for blinding, and some evidence of selective outcome reporting was found. These possible sources of bias did not lead us to downgrade the quality of the evidence. The quantity of inhaled steroids, including puffs taken for relief from symptoms, was consistently lower for SiT than for the comparison groups.Separate data for exacerbations leading to hospitalisations, to emergency room (ER) visits or to a course of oral steroids could not be obtained. Compared with higher fixed-dose combination inhalers, fewer people using SiT had exacerbations requiring hospitalisation or a visit to the ER (odds ratio (OR) 0.72, 95% confidence interval (CI) 0.57 to 0.90; I(2) = 0%, P = 0.66), and fewer had exacerbations requiring a course of oral corticosteroids (OR 0.75, 95% CI 0.65 to 0.87; I(2) = 0%, P = 0.82). This translates to one less person admitted to hospital or visiting the ER (95% CI 0 to 2 fewer) and two fewer people needing oral steroids (95% CI 1 to 3 fewer) compared with fixed-dose combination treatment with a short-acting beta-agonist (SABA) reliever (per 100 treated over eight months). No statistical heterogeneity was observed in either outcome, and the evidence was rated of high quality. Although issues with blinding were evident in two of the studies, and one study recruited a less severe population, sensitivity analyses did not change the main results, so quality was not downgraded.We could not rule out the possibility that SiT increased rates of serious adverse events (OR 0.92, 95% CI 0.74 to 1.13; I(2) = 0%, P = 0.98; moderate-quality evidence, downgraded owing to imprecision).We were unable to say whether SiT improved results for several secondary outcomes (morning and evening peak expiratory flow (PEF), rescue medication use, symptoms scales), and in cases where results were significant, the effect sizes were not considered clinically meaningful (predose FEV1, nocturnal awakenings and quality of life). AUTHORS' CONCLUSIONS: SiT reduces the number of people having asthma exacerbations requiring oral steroids and the number requiring hospitalisation or an ER visit compared with fixed-dose combination inhalers. Evidence for serious adverse events was unclear. The mean daily dose of inhaled corticosteroids (ICS) in SiT, including the total dose administered with reliever use, was always lower than that of the other combination groups. This suggests that the flexibility in steroid administration that is possible with SiT might be more effective than a standard fixed-dose combination by increasing the dose only when needed and keeping it low during stable stages of the disease. Data for hospitalisations alone could not be obtained, and no studies have yet addressed this question in children younger than age 12

Assessing the volcanic hazard for Rome. 40Ar/39Ar and In-SAR constraints on the most recent eruptive activity and present-day uplift at Colli Albani Volcanic District

We present new 40Ar/39Ar data which allow us to refine the recurrence time for the most recent eruptive activity occurred at Colli Albani Volcanic District (CAVD) and constrain its geographic area. Time elapsed since the last eruption (36 kyr) overruns the recurrence time (31 kyr) in the last 100 kyr. New interferometric synthetic aperture radar data, covering the years 1993–2010, reveal ongoing inflation with maximum uplift rates (>2 mm/yr) in the area hosting the most recent (<200 ka) vents, suggesting that the observed uplift might be caused by magma injection within the youngest plumbing system. Finally, we frame the present deformation within the structural pattern of the area of Rome, characterized by 50 m of regional uplift since 200 ka and by geologic evidence for a recent (<2000 years) switch of the local stress-field, highlighting that the precursors of a new phase of volcanic activity are likely occurring at the CAVD

Oxygen Fugacity of the Upper Mantle of Mars. Evidence from the Partitioning Behavior of Vanadium in Y980459 (Y98) and other Olivine-Phyric Shergottites

Using partitioning behavior of V between olivine and basaltic liquid precisely calibrated for martian basalts, we determined the redox state of primitive (olivine-rich, high Mg#) martian basalts near their liquidus. The combination of oxidation state and incompatible element characteristics determined from early olivine indicates that correlations between fO2 and other geochemical characteristics observed in many martian basalts is also a fundamental characteristic of these primitive magmas. However, our data does not exhibit the range of fO2 observed in these previous studies.. We conclude that the fO2 for the martian upper mantle is approximately IW+1 and is incompatible-element depleted. It seems most likely (although clearly open to interpretation) that these mantle-derived magmas assimilated a more oxidizing (>IW+3), incompatible-element enriched, lower crustal component as they ponded at the base of the martian crust

Racing climate change: Collaboration and conflict in California's global climate change policy arena

Media accounts routinely refer to California's Assembly Bill 32 (AB 32), the Global Warming Solutions Act of 2006, as "landmark" climate change legislation. On its surface, this label is an accurate reflection of the state's forward-thinking stance across many environmental issues including pesticides, toxic substances, solid waste, and air quality. For all its promise, however, AB 32 can also be considered a low point in the landscape of conflict between state environmental regulators and California's environmental justice movement. While the legislation included several provisions to address the procedural and distributive dimensions of environmental justice, the implementation of AB 32 has been marked by heated conflict. The most intense conflicts over AB 32 revolve around the primacy of market mechanisms such as "cap and trade." This article examines the drivers and the manifestations of these dynamics of collaboration and conflict between environmental justice advocates and state regulators, and pays particular attention to the scalar and racialized quality of the neoliberal discourse. The contentiousness of climate change politics in California offers scholars and practitioners around the world a cautionary tale of how the best intentions for integrating environmental justice principles into climate change policy do not necessarily translate into implementation and how underlying racialized fractures can upend collaboration between state and social movement actors. © 2013 Elsevier Ltd

Balancing competing policy demands: the case of sustainable public sector food procurement.

A focus on market-based green growth strategies to pursue sustainability goals neglects the pursuit of understanding how human health is interwoven with the health of eco-systems to deliver sustainability goals. The article argues that clarifying the difference between green and sustainable public sector food procurement, with political continuity that supports and enables policymakers and practitioners to take an incremental approach to change, makes an important contribution to delivering more sustainable food systems and better public health nutrition. Five European case studies demonstrate the reality of devising and implementing innovative approaches to sustainable public sector food procurement and the effects of cultural and political framings. How legislation is enacted at the national level and interpreted at the local level is a key driver for sustainable procurement. Transition is dependent on political will and leadership and an infrastructure that can balance the economic, environmental and social drivers to effect change. The development of systems and indicators to measure change, reforms to EU directives on procurement, and the relationship between green growth strategies and sustainable diets are also discussed. The findings show the need to explore how consistent definitions for green public procurement and sustainable public procurement can be refined and standardized in order to support governments at all levels in reviewing and analyzing their current food procurement strategies and practices to improve sustainability

Genetic analysis of multiple synchronous lesions of the colon adenoma–carcinoma sequence

The colorectal adenoma–carcinoma sequence represents a well-known paradigm for the sequential development of cancer driven by the accumulation of genomic defects. Although the colorectal adenoma–carcinoma sequence is well investigated, studies about tumours of different dignity co-existent in the same patient are seldom. In order to address the distribution of genetic alterations in different lesions of the same patient, we coincidently investigated carcinomas, adenomas and aberrant crypt foci in patients with sporadic colon cancer. By utilizing polymerase chain reaction, single-strand conformation polymorphism, heteroduplex-analysis, restriction fragment length polymorphism, protein truncation test and sequencing techniques we looked for mutations and microsatellite instability of APC, H- ras, K- ras, p53, DCC and the DNA repair genes hMLH1/hMSH2. In accordance with the suggested adenoma–carcinoma sequence of the colon, four patients reflected the progressive accumulation of genetic defects in synchronously appearing tumours during carcinogenesis. However, two patients with non-hereditary malignomas presented different genetic instabilities in different but synchronously appearing tumours suggesting non-clonal growth under almost identical conditions of the environment. Thus, sporadically manifesting multiple lesions of the colon were not necessarily driven by similar genetic mechanisms. Premalignant lesions may transform into malignant tumours starting from different types of genetic instability, which indicates independent and simultaneous tumorigenesis within the same organ. © 2000 Cancer Research Campaig

U.S. Department of Energy -- Advanced Vehicle Testing Activity: Plug-in Hybrid Electric Vehicle Testing and Demonstration Activities

The U.S. Department of Energy’s (DOE) Advanced Vehicle Testing Activity (AVTA) tests plug-in hybrid electric vehicles (PHEV) in closed track, dynamometer and onroad testing environments. The onroad testing includes the use of dedicated drivers on repeated urban and highway driving cycles that range from 10 to 200 miles, with recharging between each loop. Fleet demonstrations with onboard data collectors are also ongoing with PHEVs operating in several dozen states and Canadian Provinces, during which trips- and miles-per-charge, charging demand and energy profiles, and miles-per-gallon and miles-per-kilowatt-hour fuel use results are all documented, allowing an understanding of fuel use when vehicles are operated in charge depleting, charge sustaining, and mixed charge modes. The intent of the PHEV testing includes documenting the petroleum reduction potential of the PHEV concept, the infrastructure requirements, and operator recharging influences and profiles. As of May 2008, the AVTA has conducted track and dynamometer testing on six PHEV conversion models and fleet testing on 70 PHEVs representing nine PHEV conversion models. A total of 150 PHEVs will be in fleet testing by the end of 2008, all with onboard data loggers. The onroad testing to date has demonstrated 100+ miles per gallon results in mostly urban applications for approximately the first 40 miles of PHEV operations. The primary goal of the AVTA is to provide advanced technology vehicle performance benchmark data for technology modelers, research and development programs, and technology goal setters. The AVTA testing results also assist fleet managers in making informed vehicle purchase, deployment and operating decisions. The AVTA is part of DOE’s Vehicle Technologies Program. These AVTA testing activities are conducted by the Idaho National Laboratory and Electric Transportation Engineering Corporation, with Argonne National Laboratory providing dynamometer testing support. The proposed paper and presentation will discuss PHEV testing activities and results. INL/CON-08-1433

Valence State Partitioning of Cr and V Between Pyroxene - Melt: Estimates of Oxygen Fugacity for Martian Basalt QUE 94201

Several studies, using different oxybarometers, have suggested that the variation of fO2 in martian basalts spans about 3 log units from approx. IW-1 to IW+2. The relatively oxidized basalts (e.g., pyroxene-phyric Shergotty) are enriched in incompatible elements, while the relatively reduced basalts (e.g., olivine-phyric Y980459) are depleted in incompatible elements. A popular interpretation of the above observations is that the martian mantle contains two reservoirs; 1) oxidized and enriched, and 2) reduced and depleted. The basalts are thus thought to represent mixing between these two reservoirs. Recently, Shearer et al. determined the fO2 of primitive olivine-phyric basalt Y980459 to be IW+0.9 using the partitioning of V between olivine and melt. In applying this technique to other basalts, Shearer et al. concluded that the martian mantle shergottite source was depleted and varied only slightly in fO2 (IW to IW+1). Thus the more oxidized, enriched basalts had assimilated a crustal component on their path to the martian surface. In this study we attempt to address the above debate on martian mantle fO2 using the partitioning of Cr and V into pyroxene in pyroxene-phyric basalt QUE 94201