Combination inhaled steroid and long-acting beta2-agonist versus tiotropium for chronic obstructive pulmonary disease

Background Combination therapy (inhaled corticosteroids and long-acting beta(2)-agonists) and tiotropium are both used in the treatment of chronic obstructive pulmonary disease (COPD). There is uncertainty about the relative benefits and harms of these treatments. Objectives To assess the relative effects of inhaled combination therapy and tiotropium on patients with COPD. Search strategy We searched the Cochrane Airways Group Specialised Register of trials (March 2010) and reference lists of articles. We also contacted authors of the studies.Selection criteriaWe included only parallel, randomised controlled trials comparing inhaled combination corticosteroid and long-acting beta(2)-agonist against inhaled tiotropium bromide. Data collection and analysis Two authors independently assessed trials for inclusion and then extracted data on trial quality and outcome results. We contacted study authors for additional information. Discrepancies were resolved through discussion. Main results One large two year trial (INSPIRE) and two smaller, shorter trials (Dawber 2005; SCO40034) were found. The results from these trials were not pooled. The number of withdrawals from each arm of the INSPIRE trial was large and imbalanced and outcome data was not collected for patients who withdrew, raising concerns about the reliability of data from this study.In INSPIRE, there were more deaths on tiotropium than on fluticasone/salmeterol (Peto OR 0.55; 95% CI 0.33 to 0.93). This was a statistically significant difference, however the number of withdrawals from each of the arms was eleven times larger than the observed number of deaths for participants on fluticasone/salmeterol and seven times larger for participants on tiotropium. There were more all cause hospital admissions in patents on fluticasone/salmeterol than those on tiotropium in INSPIRE (Peto OR 1.32; 95% CI 1.04 to 1.67). There was no statistically significant difference in hospital admissions due to exacerbations, the primary outcome of INSPIRE. There was no significant difference in exacerbations in patients on fluticasone/salmeterol compared to tiotropium. Exacerbations requiring treatment with oral corticosteroids were less frequent in patients on fluticasone/salmeterol (Rate Ratio 0.81; 95% CI 0.67 to 0.99). Conversely exacerbations requiring treatment with antibiotics were more frequent in patients treated with fluticasone/salmeterol (Rate Ratio 1.19; 95% CI 1.02 to 1.38). There were more cases of pneumonia in patients on fluticasone/salmeterol than those on tiotropium (Peto OR 2.13; 95% CI 1.33 to 3.40). Confidence intervals for these outcomes do not reflect the additional uncertainty arising from unknown outcome data for patients who withdrew. Authors' conclusions Since the proportion of missing outcome data compared to the observed outcome data is enough to induce a clinically relevant bias in the intervention effect, the relative efficacy and safety of combined inhalers and tiotropium remains uncertain. Further large, long-term randomised controlled trials comparing combination therapy to tiotropium are required, including adequate follow-up of all participants randomised (similar to the procedures undertaken in TORCH and UPLIFT). Additional studies comparing alternative inhaled LABA/steroid combination therapies with tiotropium are also required

Reduced-Order Modelling of the Bending of an Array of Torsional Micromirrors

Reduced-Order Modelling of the Bending of an Array of An array of micromirrors for beam steering optical switching has been designed in a thick polysilicon technology. A novel semi-analytical method to calculate the static characteristics of the micromirrors by taking into account the flexural deformation of the structure is presented. The results are compared with 3D coupled-field FEM simulation.Comment: Submitted on behalf of TIMA Editions (http://irevues.inist.fr/tima-editions

LO STATO DEL PORTO NEL DIRITTO INTERNAZIONALE

The thesis aims at appraising the role of port state in international law by analyzing the whole of rights, duties and obligations ascribed to it by relevant legal instruments adopted in various fields of the law of the sea. After considering some preliminary questions, namely the notion of \u201cport state\u201d in opposition to coastal and flag states, the first chapter deals with the legal regime of port state extra-territorial jurisdiction under Article 218 of the United Nations Convention on the Law of the Sea and other relevant provisions of this Convention. In the second chapter, the focus is on Port State Control as provided by a number of international legal conventions and soft law instruments relating to the prevention of marine pollution, safety and security matters as a complementary tool to the flag state principle. The next two chapters further address the responsibility assumed by port states to ensure compliance and implementation of international rules and standards concerning living and working conditions of seafarers on board merchant and fishing ships as well as port state measures adopted at the international and regional level in order to curb the phenomenon of illegal, unregulated and unauthorized fishing on the high sea. Subsequent chapters explore the various regional memoranda of understanding on Port State Control and the rights and obligations of EU members acting as port states under the relevant EU legislation. Finally, the research undertaken shows that the role of port state under international law has gone through significant changes both from a quantitative and qualitative perspective. Thus, it may be argued that port state is being more and more considered as acting for the protection of common values and goods

Voluminous yet Vacuous? Semantic Capital in an Age of Large Language Models

Large Language Models (LLMs) have emerged as transformative forces in the realm of natural language processing, wielding the power to generate human-like text. However, despite their potential for content creation, they carry the risk of eroding our Semantic Capital (SC) - the collective knowledge within our digital ecosystem - thereby posing diverse social epistemic challenges. This paper explores the evolution, capabilities, and limitations of these models, while highlighting ethical concerns they raise. The study contribution is two-fold: first, it is acknowledged that, withstanding the challenges of tracking and controlling LLM impacts, it is necessary to reconsider our interaction with these AI technologies and the narratives that form public perception of them. It is argued that before achieving this goal, it is essential to confront a potential deontological tipping point in an increasing AI-driven infosphere. This goes beyond just adhering to AI ethical norms or regulations and requires understanding the spectrum of social epistemic risks LLMs might bring to our collective SC. Secondly, building on Luciano Floridi's taxonomy for SC risks, those are mapped within the functionality and constraints of LLMs. By this outlook, we aim to protect and enrich our SC while fostering a collaborative environment between humans and AI that augments human intelligence rather than replacing it

The Future of Churches - Identity System for the Valorization of Local Contexts

The "Future of Churches" has been an international symposium organised by the Department of Architecture of the University of Bologna, the Archidioceses of Bologna, FTER - Theological Faculty of Emilia-Romagna and Centro Studi Ghirardacci. It took place in Bologna between 5th and 7th October 2016 and more than fifty international researchers attended this meeting, under the Carracci's frescos in Palazzo Magnani

The City as a Gravel Pile: Building Codes, Concrete, and Urban Dwellings in Reykjavík (1903–45)

This paper deals with the urban development of Reykjavík during the first half of the 20th century, with particular attention to building techniques and their influence in the construction of a modern capital city for Iceland. By analysing its first building codes (issued in 1903 and in 1945) and some examples of residential typologies built in that same period, this research highlights the special role that concrete played in the growth and modernisation of Reykjavík

The veil of the body. Emotions and expressive mimesis in Johann Jakob Engel’s aesthetic thought

In the present article, I intend to examine the importance of Engel’s mimicry for the corporeal visualization of affects, showing the links with its roots in the early German Enlightenment. If the body serves as a picture of the soul, the aim of this essay is to understand how Engel’s mimicry turns this correspondence to its own purpose, enhancing its role as a privileged observatory of the human mind as well as a building site of a historical form of humanity