Combination inhaled steroid and long-acting beta-agonist in addition to tiotropium versus tiotropium or combination alone for chronic obstructive pulmonary disease (Review)

Background The long-acting bronchodilator tiotropium and single inhaler combination therapy of inhaled corticosteroids and long-acting beta(2)-agonists are both commonly used for maintenance treatment of chronic obstructive pulmonary disease. Combining these treatments, which have different mechanisms of action, may be more effective than the individual components. However, the benefits and risks of using tiotropium and combination therapy together for the treatment of chronic obstructive pulmonary disease are unclear. Objectives To assess the relative effects of inhaled corticosteroid and long-acting beta(2)-agonist combination therapy in addition to tiotropium compared to tiotropium or combination therapy alone in patients with chronic obstructive pulmonary disease. Search methods We searched the Cochrane Airways Group Specialised Register of trials (July 2010) and reference lists of articles. Selection criteria We included parallel, randomised controlled trials of three months or longer, comparing inhaled corticosteroid and long-acting beta(2)-agonists combination therapy in addition to inhaled tiotropium against tiotropium alone or combination therapy alone. Data collection and analysis We independently assessed trials for inclusion and then extracted data on trial quality and outcome results. We contacted study authors for additional information. We collected information on adverse effects from the trials. Main results Three trials (1021 patients) were included comparing tiotropium in addition to inhaled corticosteroid and long-acting beta2-agonist combination therapy to tiotropium alone. The duration, type of combination treatment and definition of outcomes varied. The limited data led to wide confidence intervals and there was no significant statistical difference in mortality, participants with one or more hospitalisations, episodes of pneumonia or adverse events. The results on exacerbations were heterogeneous and were not combined. The mean health-related quality of life and lung function were significantly different when combination therapy was added to tiotropium, although the size of the average benefits of additional combination therapy were small, St George's Respiratory Questionnaire (MD -2.49; 95% CI -4.04 to -0.94) and forced expiratory volume in one second (MD 0.06 L; 95% CI 0.04 to 0.08).One trial (60 patients) compared tiotropium plus combination therapy to combination therapy alone. The results from the trial were insufficient to draw firm conclusions for this comparison. Authors' conclusions To date there is uncertainty regarding the long-term benefits and risks of treatment with tiotropium in addition to inhaled corticosteroid and long-acting beta(2)-agonist combination therapy on mortality, hospitalisation, exacerbations of COPD and pneumonia. The addition of combination treatment to tiotropium has shown improvements in average health-related quality of life and lung function

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

A case for mutual engagement: On the consequences of professor as terminal audience

As a student in the final throes of undergraduate work, I\u27ve begun to look back at my college career and consider the academic experiences that made me into the writer I am today. The element that most intrigues me is the role my professors have had in shaping my writing voice and approach, and as I move forward in academia, I can\u27t help but wonder about the dynamic between the student writer and the professor reader. Academic writing, to me, has sometimes felt bound within the four walls of the institution, making the writing I have done for classes feel like it is meant for professors\u27 eyes only. I wonder what effect this single audience has had in shaping me as an academic writer. Obviously there are times and classes where having a sole reader of work is both appropriate and freeing, and this is especially true in early composition classes where student writers are developing confidence. But, for me, this dynamic did not change much as I progressed through my undergraduate degree, and I have to imagine that this constant and familiar single audience played a part in molding who I am as an academic writer. So, I set out to discover the effects a professor has on student writing when acting as a terminal audience. Do students approach academic writing for a professor differently than they approach self-directed writing? How do students view their class assignments in terms of their validity for publication or even for sharing with loved ones? And what are the alternatives to having the professor act as a sole audience? These are the questions I intend to answer

Yona Friedman. Mobile Architecture, People’s Architecture. Review of The Exhibition Curated by Gong Yan and Elena Motisi

Two years after Shanghai Power Station of Art's "Yona Friedman. Mobile Architecture" (2015), Rome's MAXXI Museum displays the work of this giant of architectural theory, adding the importance of the people and of the individual within Yona Friedman's design proposals. The outcome is a cheerful and ironic exhibit through Friedman's architecture and thoughts

Icelandic Concrete Surfaces: Guðjón Samúelsson’s Steining (1930–50)

In 1939, Iceland’s State Architect Guðjón Samúelsson (1887–1950) filed a patent for the “Improvements in or relating to Treating the Surfaces of Buildings and other Structures, particularly of Concrete” (GB 516,064, 21-12-1939), although the Steining technique had already been used in Reykjavík for a few years, developed by several local builders working for the State Architect. This Icelandic version of pebbledash, whose outcomes were “a very neat appearance” of “already built buildings and other structures, particularly of concrete” and a greater resistance against the “rigorous climatic conditions”, was to cover almost all concrete surfaces of Reykjavík, until the late 1950s. The technique consisted in the application of a layer of stone fragments on a thin layer of cement mortar, manually applied, with the help of a trowel. Steining could avoid the inaccuracies on concrete surfaces, in a country where the labour force was not particularly skilled, and was a protection against the cold climate. It also had visual outcomes: on the one hand, the use of local aggregates such as quartz and obsidian generated a concrete polychromy that spanned from darker to lighter shades; on the other, such fragments became an architectural mirror of the Icelandic geology and, consequently, a built ode to the island’s natural landscape. Until now, Steining has been studied from a conservation point of view by the Icelandic literature (Ári Trausti Guðmundsson, Flósi Ólafsson 2003), and within the development of an Icelandic architectural modernity (Seelow 2011). Analysing its most peculiar applications, namely Reykjavík’s National Theatre (1928–50) and the University of Iceland (1934–40), this research aims at placing Steining within a wider history of construction. The main scope is to trace the connections between Steining and similar concrete surfaces employed in the same years in Northern Europe and to define its role in the development of the Icelandic architecture