β-Lactam Monotherapy vs β-Lactam-Macrolide Combination Treatment in Moderately Severe Community-Acquired Pneumonia: A Randomized Noninferiority Trial.

IMPORTANCE: The clinical benefit of adding a macrolide to a β-lactam for empirical treatment of moderately severe community-acquired pneumonia remains controversial. OBJECTIVE: To test noninferiority of a β-lactam alone compared with a β-lactam and macrolide combination in moderately severe community-acquired pneumonia. DESIGN, SETTING, AND PARTICIPANTS: Open-label, multicenter, noninferiority, randomized trial conducted from January 13, 2009, through January 31, 2013, in 580 immunocompetent adult patients hospitalized in 6 acute care hospitals in Switzerland for moderately severe community-acquired pneumonia. Follow-up extended to 90 days. Outcome assessors were masked to treatment allocation. INTERVENTIONS: Patients were treated with a β-lactam and a macrolide (combination arm) or with a β-lactam alone (monotherapy arm). Legionella pneumophila infection was systematically searched and treated by addition of a macrolide to the monotherapy arm. MAIN OUTCOMES AND MEASURES: Proportion of patients not reaching clinical stability (heart rate <100/min, systolic blood pressure >90 mm Hg, temperature <38.0°C, respiratory rate <24/min, and oxygen saturation >90% on room air) at day 7. RESULTS: After 7 days of treatment, 120 of 291 patients (41.2%) in the monotherapy arm vs 97 of 289 (33.6%) in the combination arm had not reached clinical stability (7.6% difference, P = .07). The upper limit of the 1-sided 90% CI was 13.0%, exceeding the predefined noninferiority boundary of 8%. Patients infected with atypical pathogens (hazard ratio [HR], 0.33; 95% CI, 0.13-0.85) or with Pneumonia Severity Index (PSI) category IV pneumonia (HR, 0.81; 95% CI, 0.59-1.10) were less likely to reach clinical stability with monotherapy, whereas patients not infected with atypical pathogens (HR, 0.99; 95% CI, 0.80-1.22) or with PSI category I to III pneumonia (HR, 1.06; 95% CI, 0.82-1.36) had equivalent outcomes in the 2 arms. There were more 30-day readmissions in the monotherapy arm (7.9% vs 3.1%, P = .01). Mortality, intensive care unit admission, complications, length of stay, and recurrence of pneumonia within 90 days did not differ between the 2 arms. CONCLUSIONS AND RELEVANCE: We did not find noninferiority of β-lactam monotherapy in patients hospitalized for moderately severe community-acquired pneumonia. Patients infected with atypical pathogens or with PSI category IV pneumonia had delayed clinical stability with monotherapy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00818610.

The role of teriparatide in sequential and combination therapy of osteoporosis.

Osteoporosis is complicated by the occurrence of fragility fractures. Over past years, various treatment options have become available, mostly potent antiresorptive agents such as bisphosphonates and denosumab. However, antiresorptive therapy cannot fully and rapidly restore bone mass and structure that has been lost because of increased remodelling. Alternatively recombinant human parathyroid hormone (rhPTH) analogues do increase the formation of new bone material. The bone formation stimulated by intermittent PTH analogues not only increases bone mineral density (BMD) and bone mass but also improves the microarchitecture of the skeleton, thereby reducing incidence of vertebral and nonvertebral fractures. Teriparatide, a recombinant human PTH fragment available in Switzerland, is reimbursed as second-line treatment in postmenopausal women and men with increased fracture risk, specifically in patients with incident fractures under antiresorptive therapy or patients with glucocorticoid-induced osteoporosis and intolerance to antiresorptives. This position paper focuses on practical aspects in the management of patients on teriparatide treatment. Potential first-line indications for osteoanabolic treatment as well as the benefits and limitations of sequential and combination therapy with antiresorptive drugs are discussed.

Fluoroscopic-Guided Radial Endobronchial Ultrasound Without Guide Sheath For Peripheral Pulmonary Lesions: A Safe And Efficient Combination.

BACKGROUND: Several guidelines recommend computed tomography scans for populations with high-risk for lung cancer. The number of individuals evaluated for peripheral pulmonary lesions (PPL) will probably increase, and with it non-surgical biopsies. Associating a guidance method with a target confirmation technique has been shown to achieve the highest diagnostic yield, but the utility of bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy as guidance without a guide sheath has not been reported. METHODS: We conducted a retrospective analysis of bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy procedures for the investigation of PPL performed by experienced bronchoscopists with no specific previous training in this particular technique. Operator learning curves and radiological predictors were assessed for all consecutive patients examined during the first year of application of the technique. RESULTS: Fifty-one PPL were investigated. Diagnostic yield and visualization yield were 72.5 and 82.3% respectively. The diagnostic yield was 64.0% for PPL ≤20mm, and 80.8% for PPL>20mm. No false-positive results were recorded. The learning curve of all diagnostic tools showed a DY of 72.7% for the first sub-group of patients, 81.8% for the second, 72.7% for the third, and 81.8% for the last. CONCLUSION: Bronchoscopy with radial probe endobronchial ultrasound using fluoroscopy as guidance is safe and simple to perform, even without specific prior training, and diagnostic yield is high for PPL>and ≤20mm. Based on these findings, this method could be introduced as a first-line procedure for the investigation of PPL, particularly in centers with limited resources.

A Novel Accelerator Combination for the Low Temperature Curing of Silica-Filled NBR Compounds

Zinc salts of ethyl, isopropyl, and butyl xanthates were prepared in the laboratory. The effect of these xanthates in combination with zinc diethyldithiocarbamate (ZDC) on the vulcanization of silica-filled NBR compounds has been studied at different temperatures. The cure times of these compounds were compared with that of NBR compounds containing tetramethylthiuram disulphide/dibenzthiazyl disulphide. The rubber compounds with the xanthates and ZDC were cured at various temperatures from 60 to 150°C. The sheets were molded and properties such as tensile strength, tear strength, crosslink density, elongation at break, compression set, abrasion resistance, flex resistance, heat buildup, etc. were evaluated. The properties showed that zinc salt of xanthate/ZDC combination has a positive synergistic effect on the cure rate and mechanical properties of NBR compounds.

Studies on Xanthate/Dithiocarbamate Accelerator Combination in NR/BR Blends

Zinc butyl xanthate [Zn(bxt)2] was prepared in the laboratory . The effect of this xanthate with zinc diethyl dithiocarbamate (ZDC) on the vulcanization of natural rubber ( NR), polybutadiene rubber (BR), and NR/BR blend has been studied at different temperatures. The amounts of Zn (bxt)2 and ZDC in the compounds were optimized by varying the amount of ZDC from 0 . 75 to 1.5 phr and Zn (bxt)2 from 0 . 75 to 1 .5 phr. The cure characteristics were also studied . HAF filled NR, BR, and NR / BR blend compounds were cured at different temperatures from 60 to 150 C. The sheets were molded and properties such as tensile strength, tear strength, crosslink density and elongation at break, compression set, abrasion resistance, etc. were evaluated. The results show that the mechanical properties of 80NR/20BR blends are closer to that of NR vulcanizates, properties of 60NR/40BR blends are closer to BR vulcanizates, while the 70NR/30BR blends show an intermediate property.

Investigations on the Dynamics of Combination Maps and the Analysis of Bifurcation in a Discontinuous Logistic Map

This thesis is a study of discrete nonlinear systems represented by one dimensional mappings.As one dimensional interative maps represent Poincarre sections of higher dimensional flows,they offer a convenient means to understand the dynamical evolution of many physical systems.It highlighting the basic ideas of deterministic chaos.Qualitative and quantitative measures for the detection and characterization of chaos in nonlinear systems are discussed.Some simple mathematical models exhibiting chaos are presented.The bifurcation scenario and the possible routes to chaos are explained.It present the results of the numerical computational of the Lyapunov exponents (λ) of one dimensional maps.This thesis focuses on the results obtained by our investigations on combinations maps,scaling behaviour of the Lyapunov characteristic exponents of one dimensional maps and the nature of bifurcations in a discontinous logistic map.It gives a review of the major routes to chaos in dissipative systems,namely, Period-doubling ,Intermittency and Crises.This study gives a theoretical understanding of the route to chaos in discontinous systems.A detailed analysis of the dynamics of a discontinous logistic map is carried out, both analytically and numerically ,to understand the route it follows to chaos.The present analysis deals only with the case of the discontinuity parameter applied to the right half of the interval of mapping.A detailed analysis for the n –furcations of various periodicities can be made and a more general theory for the map with discontinuities applied at different positions can be on a similar footing

Nitrogen in combination with Desmodium intortum effectively suppress Striga asiatica in a sorghum‒Desmodium intercropping system

It is well known that the parasitic weed Striga asiatica (L.) Kuntze can be suppressed by Striga-tolerant sorghum (Sorghum bicolor L. Moench) cultivars, Desmodium intortum (Mill.) Urb. (greanleaf desmodium), and by fertilization with nitrogen. The study objective was the assessment of Striga control provided by integration of Desmodium density, timing of sorghum-Desmodium intercrop establishment, and nitrogen fertilization. Growth responses and yield of three sorghum cultivars were measured in three pot experiments. A soil naturally infested with Striga was used, and that part of the soil which served as uninfested control was chemically sterilised. Striga numbers and growth were affected significantly by sorghum cultivars, sorghum-Desmodium intercrop ratios, timing of the sorghum-Desmodium association, as well as by their interactions. Desmodium caused 100% suppression of Striga emergence when Desmodium was established in the 1:3 sorghum-Desmodium ratio at seeding of sorghum. Total control of Striga was also achieved with the 1:1 sorghum-Desmodium ratio when Desmodium was transplanted 30 days before sorghum seeding. However, these two treatments also caused significant reductions in sorghum yield. In contrast, 100% Striga control and a dramatic increase in sorghum yield were achieved with 100 kg N ha^{-1} in the 1:1 sorghum-Desmodium intercrop. Compatibility of sorghum and Desmodium was evident at the 1:1 sorghum-Desmodium intercrop established at sorghum seeding. Overall, the Ethiopian cultivars Meko and Abshir showed better agronomic performance and higher tolerance to Striga than the South African cultivar PAN 8564. It is recommended that the N × Desmodium × sorghum interaction be investigated under field conditions.

Slow and Smooth: A Bayesian Theory for the Combination of Local Motion Signals in Human Vision

In order to estimate the motion of an object, the visual system needs to combine multiple local measurements, each of which carries some degree of ambiguity. We present a model of motion perception whereby measurements from different image regions are combined according to a Bayesian estimator --- the estimated motion maximizes the posterior probability assuming a prior favoring slow and smooth velocities. In reviewing a large number of previously published phenomena we find that the Bayesian estimator predicts a wide range of psychophysical results. This suggests that the seemingly complex set of illusions arise from a single computational strategy that is optimal under reasonable assumptions.

Convex linear combination processes for compositions

Aitchison and Bacon-Shone (1999) considered convex linear combinations of compositions. In other words, they investigated compositions of compositions, where the mixing composition follows a logistic Normal distribution (or a perturbation process) and the compositions being mixed follow a logistic Normal distribution. In this paper, I investigate the extension to situations where the mixing composition varies with a number of dimensions. Examples would be where the mixing proportions vary with time or distance or a combination of the two. Practical situations include a river where the mixing proportions vary along the river, or across a lake and possibly with a time trend. This is illustrated with a dataset similar to that used in the Aitchison and Bacon-Shone paper, which looked at how pollution in a loch depended on the pollution in the three rivers that feed the loch. Here, I explicitly model the variation in the linear combination across the loch, assuming that the mean of the logistic Normal distribution depends on the river flows and relative distance from the source origins

Combination treatment in the rehabilitation of visuo-spatial neglect

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Cue combination for 3D location judgements

Cue combination rules have often been applied to the perception of surface shape but not to judgements of object location. Here, we used immersive virtual reality to explore the relationship between different cues to distance. Participants viewed a virtual scene and judged the change in distance of an object presented in two intervals, where the scene changed in size between intervals (by a factor of between 0.25 and 4). We measured thresholds for detecting a change in object distance when there were only 'physical' (stereo and motion parallax) or 'texture-based' cues (independent of the scale of the scene) and used these to predict biases in a distance matching task. Under a range of conditions, in which the viewing distance and position of the tarte relative to other objects was varied, the ration of 'physical' to 'texture-based' thresholds was a good predictor of biases in the distance matching task. The cue combination approach, which successfully accounts for our data, relies on quite different principles from those underlying geometric reconstruction.

Ex Vivo Construction of an Artificial Ocular Surface by Combination of Corneal Limbal Epithelial Cells and a Compressed Collagen Scaffold Containing Keratocytes

We have investigated the use of a laminin coated compressed collagen gel containing corneal fibroblasts (keratocytes) as a novel scaffold to support the growth of corneal limbal epithelial stem cells. The growth of limbal epithelial cells was compared between compressed collagen gel and a clinically proven conventional substrate, denuded amniotic membrane. Following compression of the collagen gel, encapsulated keratocytes remained viable and scanning electron microscopy showed that fibres within the compressed gel were dense, homogeneous and similar in structure to those within denuded amniotic membrane. Limbal epithelial cells were successfully expanded upon the compressed collagen resulting in stratified layers of cells containing desmosome and hemidesmosome structures. The resulting corneal constructs of both the groups shared a high degree of transparency, cell morphology and cell stratification. Similar protein expression profiles for cytokeratin 3 and cytokeratin 14 and no significant difference in cytokeratin 12 mRNA expression levels by real time PCR were also observed. This study provides the first line of evidence that a laminin coated compressed collagen gel containing keratocytes can adequately support limbal epithelial cell expansion, stratification and differentiation to a degree that is comparable to the leading conventional scaffold, denuded amniotic membrane.

Combination therapy: opportunities and challenges for polymer-drug conjugates as anticancer nanomedicines.

The discovery of new molecular targets and the subsequent development of novel anticancer agents are opening new possibilities for drug combination therapy as anticancer treatment. Polymer-drug conjugates are well established for the delivery of a single therapeutic agent, but only in very recent years their use has been extended to the delivery of multi-agent therapy. These early studies revealed the therapeutic potential of this application but raised new challenges (namely, drug loading and drugs ratio, characterisation, and development of suitable carriers) that need to be addressed for a successful optimisation of the system towards clinical applications.