Levonorgestrel intrauterine system versus medical therapy for menorrhagia

Background - Menorrhagia is a common problem, yet evidence to inform decisions about therapy is limited. In a pragmatic, multicenter, randomized trial, we compared the levonorgestrel-releasing intrauterine system (levonorgestrel-IUS) with usual medical treatment in women with menorrhagia who presented to their primary care providers. Methods - We randomly assigned 571 women with menorrhagia to treatment with levonorgestrel-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined estrogen–progestogen, or progesterone alone). The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) (ranging from 0 to 100, with lower scores indicating greater severity), assessed over a 2-year period. Secondary outcomes included general quality-of-life and sexual-activity scores and surgical intervention. Results - MMAS scores improved from baseline to 6 months in both the levonorgestrel-IUS group and the usual-treatment group (mean increase, 32.7 and 21.4 points, respectively; P<0.001 for both comparisons). The improvements were maintained over a 2-year period but were significantly greater in the levonorgestrel-IUS group than in the usual-treatment group (mean between-group difference, 13.4 points; 95% confidence interval, 9.9 to 16.9; P<0.001). Improvements in all MMAS domains (practical difficulties, social life, family life, work and daily routine, psychological well-being, and physical health) were significantly greater in the levonorgestrel-IUS group than in the usual-treatment group, and this was also true for seven of the eight quality-of-life domains. At 2 years, more of the women were still using the levonorgestrel-IUS than were undergoing the usual medical treatment (64% vs. 38%, P<0.001). There were no significant between-group differences in the rates of surgical intervention or sexual-activity scores. There were no significant differences in serious adverse events between groups. Conclusions - In women with menorrhagia who presented to primary care providers, the levonorgestrel-IUS was more effective than usual medical treatment in reducing the effect of heavy menstrual bleeding on quality of life. (Funded by the National Institute of Health Research Health Technology Assessment Programme; ECLIPSE Controlled-Trials.com number, ISRCTN86566246.)

Levonorgestrel intrauterine system versus medical therapy for menorrhagia

ABSTRACT: Menorrhagia is a common problem that interferes with a woman’s physical, emotional, and social life. Evidence to guide physicians for decision about therapy for heavy menstrual bleeding is lacking. One treatment option, the levonorgestrel-releasing intrauterine system (levonorgestrel-IUS), has been available in the United States since 2009. Updated meta-analyses comparing the levonorgestrel-IUS with nonhormonal and hormonal treatments showed that the levonorgestrel-IUS produced a greater reduction in menstrual blood loss at 3 to 12 months of follow-up. It is not clear whether these short-term benefits persist. Moreover, the rates of discontinuation of the levonorgestrel-IUS at 2 years are as high as 28%, and effects on bleeding-related quality of life are not known. This pragmatic, multicenter, randomized trial compared the effectiveness of the levonorgestrel-IUS with that of usual medical treatment among women with menorrhagia in a primary care setting. A total of 571 women with menorrhagia were randomized to treatment with levonorgestrel-IUS (n = 285) or usual medical treatment (n = 286). Usual treatment was tranexamic acid, mefenamic acid, combined estrogen-progestogen, or progesterone alone. The primary study outcome measure was the patient-reported score on the condition-specific Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period. The MMAS scores range from 0 to 100, with lower scores indicating greater severity. Summary MMAS scores were assessed at 6, 12, and 24 months. Secondary outcome measures included general health-related quality of life, sexual-activity scores, and surgical intervention. There was a significant improvement in total MMAS scores from baseline to 6 months in both the levonorgestrel-IUS group and the usual-treatment group; the mean increase was 32.7 and 21.4 points, respectively; P < 0.001 for both comparisons. Over the 2-year follow-up, improvements were maintained in both groups but were significantly greater in the levonorgestrel-IUS group (mean between-group difference, 13.4 points; 95% confidence interval, 9.9–16.9; P < 0.001). Significantly greater improvements in all MMAS domains (practical difficulties, social life, psychological health, physical health, work and daily routine, and family life and relationships) occurred with the levonorgestrel-IUS than with the usual treatment (P < 0.001 with the use of a test for trend). This was also found for 7 of the 8 quality-of-life domains. At the 2-year end point, almost twice as many women were still using the levonorgestrel-IUS than were those receiving the usual medical treatment (64% vs 38%, P < 0.001). No significant between-group differences were noted in the rates of surgical intervention or sexual-activity scores as well as in the frequency of serious adverse events. These data show that levonorgestrel-IUS is more effective than usual medical treatment in improving the quality of life of women with menorrhagia in a primary care setting.

Intra-cavity dynamics in high power mode-locked fiber lasers

A theoretical model allows for the characterization and optimization of the intra-cavity pulse evolutions in high-power fiber lasers. Multi-parameter analysis of laser performance can be made at a fraction of the computational cost. © 2010 Optical Society of America.

Religious compliance in Islamic financial institutions

The central goal of this research is to explore the approach of the Islamic banking industry in defining and implementing religious compliance at regulatory, institutional, and individual level within the Islamic Banking and Finance (IBF) industry. It also examines the discrepancies, ambiguities and paradoxes that are exhibited in the individual and institutional behaviour in relation to the infusion and enactment of religious exigencies into compliance processes in IBF. Through the combined lenses of institutional work and a sensemaking perspective, this research portrays the practice of infusion of Islamic law in Islamic banks as being ambiguous and drifting down to the institutional and actor levels. In instances of both well-codified and non-codified regulatory frameworks for Shariah compliance, institutional rules ambiguity, rules interpretation and enactment ambiguities were found to be prevalent. The individual IBF professionals performed retrospective and prospective actions to adjust the role and rules boundaries both in the case of a Muslim and a non-Muslim country. The sensitizing concept of religious compliance is the primary theoretical contribution of this research and provides a tool to understand the nature of what constitutes Shariah compliance and the dynamics of its implementation. It helps to explain the empirical consequences of the lack of a clear definition of Shariah compliance in the regulatory frameworks and standards available for the industry. It also addresses the calls to have a clear reference on what constitute Shariah compliance in IBF as proposed in previous studies (Hayat, Butter, & Kock, 2013; Maurer, 2003, 2012; Pitluck, 2012). The methodological and theoretical perspective of this research are unique in the use of multi-level analysis and approaches that blend micro and macro perspectives of the research field, to illuminate and provide a more complete picture of religious compliance infusion and enactment in IBF.

A diversity dilemma in evolutionary markets

Markets are useful mechanisms for performing resource al- location in fully decentralised computational and other systems, since they can possess a range of desirable properties, such as efficiency, decentralisation, robustness and scalability. In this paper we investigate the behaviour of co-evolving evolutionary market agents as adaptive offer generators for sellers in a multi-attribute posted-offer market. We demonstrate that the evolutionary approach enables sellers to automatically position themselves in market niches, created by heterogeneous buyers. We find that a trade-off exists for the evolutionary sellers between maintaining high population diversity to facilitate movement between niches and low diversity to exploit the current niche and maximise cumulative payoff. We characterise the trade-off from the perspective of the system as a whole, and subsequently from that of an individual seller. Our results highlight a decision on risk aversion for resource providers, but crucially we show that rational self-interested sellers would not adopt the behaviour likely to lead to the ideal result from the system point of view.

A Log Tool for Software Systems Analyses

The article presents a new type of logs merging tool for multiple blade telecommunication systems based on the development of a new approach. The introduction of the new logs merging tool (the Log Merger) can help engineers to build a processes behavior timeline with a flexible system of information structuring used to assess the changes in the analyzed system. This logs merging system based on the experts experience and their analytical skills generates a knowledge base which could be advantageous in further decision-making expert system development. This paper proposes and discusses the design and implementation of the Log Merger, its architecture, multi-board analysis of capability and application areas. The paper also presents possible ways of further tool improvement e.g. - to extend its functionality and cover additional system platforms. The possibility to add an analysis module for further expert system development is also considered.

Randomised trial of levonorgestrel intrauterine system compared to usual medical treatment for heavy menstrual bleeding:the ECLIPSE Trial

Objective: Heavy menstrual bleeding (menorrhagia) is a common problem, yet evidence is limited to inform therapeutic decisions.We compared the levonorgestrel-releasing intrauterine system(LNG-IUS) to usual medical treatment in a pragmatic randomised trial in primary care. Methods: We randomly assigned 571 women consulting their primary care providers with menorrhagia to LNG-IUS or to usual medical treatment as clinically appropriate (tranexamic acid, mefenamic acid, combined estrogen/progestogen or progestogen only). The primary outcome was a patient-reported measure ofimpact of menorrhagia, the validated Menorrhagia Multi-Attribute Scale (MMAS), assessed over 2 years. Secondary measures included generic quality of life (SF-36), sexual activity and surgical intervention.Results MMAS scores improved from baseline in both the LNG-IUS and usual medical treatment groups by 6 months (mean increases 32.7 points versus 21.4 points, respectively; P < 0.001for both) and were maintained over 2 years, but improvements were significantly greater with LNG-IUS (mean between-group difference 13.4 points, 95%CI, 9.9–16.9; P < 0.001).All domains of MMAS (practical difficulties, social life, family life,work/daily routine, psychological well being and physical health)improved significantly more with LNG-IUS, as were seven of the eight domains of SF-36. More women were still using LNG-IUSthan usual medical treatment at 2 years (64% versus 38%,P < 0.001). There were no significant between-group differences in surgical intervention rates or sexual activity scores. There were no serious adverse events in either group.Conclusions Among women presenting to primary care providers with menorrhagia, LNG-IUS was more effective than usual medical treatment at reducing the impact of this problem on their quality of life. In practice therefore, conventional treatments, such as tranexamic and mefenamic acid, remain helpful choices in women for whom LNG-IUS is considered unsuitable, or due to individual preference. For other women, LNG-IUS can be confidently recommended as an effective initial medical therapy for menorrhagia. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 02/06/02)

On optimal completions of incomplete pairwise comparison matrices

An important variant of a key problem for multi-attribute decision making is considered. We study the extension of the pairwise comparison matrix to the case when only partial information is available: for some pairs no comparison is given. It is natural to define the inconsistency of a partially filled matrix as the inconsistency of its best, completely filled completion. We study here the uniqueness problem of the best completion for two weighting methods, the Eigen-vector Method and the Logarithmic Least Squares Method. In both settings we obtain the same simple graph theoretic characterization of the uniqueness. The optimal completion will be unique if and only if the graph associated with the partially defined matrix is connected. Some numerical experiences are discussed at the end of the paper.

A method for solving LSM problems of small size in the AHP

The Analytic Hierarchy Process (AHP) is one of the most popular methods used in Multi-Attribute Decision Making. It provides with ratio-scale measurements of the prioirities of elements on the various leveles of a hierarchy. These priorities are obtained through the pairwise comparisons of elements on one level with reference to each element on the immediate higher level. The Eigenvector Method (EM) and some distance minimizing methods such as the Least Squares Method (LSM), Logarithmic Least Squares Method (LLSM), Weighted Least Squares Method (WLSM) and Chi Squares Method (X2M) are of the tools for computing the priorities of the alternatives. This paper studies a method for generating all the solutions of the LSM problems for 3 × 3 matrices. We observe non-uniqueness and rank reversals by presenting numerical results.

Solving the Least Squares Method problem in the AHP for 3 X 3 and 4 X 4 matrices

The Analytic Hierarchy Process (AHP) is one of the most popular methods used in Multi-Attribute Decision Making. The Eigenvector Method (EM) and some distance minimizing methods such as the Least Squares Method (LSM) are of the possible tools for computing the priorities of the alternatives. A method for generating all the solutions of the LSM problem for 3 × 3 and 4 × 4 matrices is discussed in the paper. Our algorithms are based on the theory of resultants.

On pairwise comparison matrices that can be made consistent by the modification of a few elements

Pairwise comparison matrices are often used in Multi-attribute Decision Making forweighting the attributes or for the evaluation of the alternatives with respect to a criteria. Matrices provided by the decision makers are rarely consistent and it is important to index the degree of inconsistency. In the paper, the minimal number of matrix elements by the modification of which the pairwise comparison matrix can be made consistent is examined. From practical point of view, the modification of 1, 2, or, for larger matrices, 3 elements seems to be relevant. These cases are characterized by using the graph representation of the matrices. Empirical examples illustrate that pairwise comparison matrices that can be made consistent by the modification of a few elements are present in the applications.

Real-time biosensor for the assessment of nanotoxicity and cancer electrotherapy

Knowledge of cell electronics has led to their integration to medicine either by physically interfacing electronic devices with biological systems or by using electronics for both detection and characterization of biological materials. In this dissertation, an electrical impedance sensor (EIS) was used to measure the electrode surface impedance changes from cell samples of human and environmental toxicity of nanoscale materials in 2D and 3D cell culture models. The impedimetric response of human lung fibroblasts and rainbow trout gill epithelial cells when exposed to various nanomaterials was tested to determine their kinetic effects towards the cells and to demonstrate the biosensor's ability to monitor nanotoxicity in real-time. Further, the EIS allowed rapid, real-time and multi-sample analysis creating a versatile, noninvasive tool that is able to provide quantitative information with respect to alteration in cellular function. We then extended the application of the unique capabilities of the EIS to do real-time analysis of cancer cell response to externally applied alternating electric fields at different intermediate frequencies and low-intensity. Decreases in the growth profiles of the ovarian and breast cancer cells were observed with the application of 200 and 100 kHz, respectively, indicating specific inhibitory effects on dividing cells in culture in contrast to the non-cancerous HUVECs and mammary epithelial cells. We then sought to enhance the effects of the electric field by altering the cancer cell's electronegative membrane properties with HER2 antibody functionalized nanoparticles. An Annexin V/EthD-III assay and zeta potential were performed to determine the cell death mechanism indicating apoptosis and a decrease in zeta potential with the incorporation of the nanoparticles. With more negatively charged HER2-AuNPs attached to the cancer cell membrane, the decrease in membrane potential would thus leave the cells more vulnerable to the detrimental effects of the applied electric field due to the decrease in surface charge. Therefore, by altering the cell membrane potential, one could possibly control the fate of the cell. This whole cell-based biosensor will enhance our understanding of the responsiveness of cancer cells to electric field therapy and demonstrate potential therapeutic opportunities for electric field therapy in the treatment of cancer.

Evaluating High-Resolution Aerial Photography Acquired by Unmanned Aerial Systems for Use in Mapping Everglades Wetland Plant Associations

Mapping of vegetation patterns over large extents using remote sensing methods requires field sample collections for two different purposes: (1) the establishment of plant association classification systems from samples of relative abundance estimates; and (2) training for supervised image classification and accuracy assessment of satellite data derived maps. One challenge for both procedures is the establishment of confidence in results and the analysis across multiple spatial scales. Continuous data sets that enable cross-scale studies are very time consuming and expensive to acquire and such extensive field sampling can be invasive. The use of high resolution aerial photography (hrAP) offers an alternative to extensive, invasive, field sampling and can provide large volume, spatially continuous, reference information that can meet the challenges of confidence building and multi-scale analysis.

Composition of sediments from the Arabian Sea

Thirty seven deep-sea sediment cores from the Arabian Sea were studied geochemically (49 major and trace elements) for four time slices during the Holocene and the last glacial, and in one high sedimentation rate core (century scale resolution) to detect tracers of past variations in the intensity of the atmospheric monsoon circulation and its hydrographic expression in the ocean surface. This geochemical multi-tracer approach, coupled with additional information on the grain size composition of the clastic fraction, the bulk carbonate and biogenic opal contents makes it possible to characterize the sedimentological regime in detail. Sediments characterized by a specific elemental composition (enrichment) originated from the following sources: river suspensions from the Tapti and Narbada, draining the Indian Deccan traps (Ti, Sr); Indus sediments and dust from Rajasthan and Pakistan (Rb, Cs); dust from Iran and the Persian Gulf (Al, Cr); dust from central Arabia (Mg); dust from East Africa and the Red Sea (Zr/Hf, Ti/Al). Corg, Cd, Zn, Ba, Pb, U, and the HREE are associated with the intensity of upwelling in the western Arabian Sea, but only those patterns that are consistently reproduced by all of these elements can be directly linked with the intensity of the southwest monsoon. Relying on information from a single element can be misleading, as each element is affected by various other processes than upwelling intensity and nutrient content of surface water alone. The application of the geochemical multi-tracer approach indicates that the intensity of the southwest monsoon was low during the LGM, declined to a minimum from 15,000-13,000 14C year BP, intensified slightly at the end of this interval, was almost stable during the Bölling, Alleröd and the Younger Dryas, but then intensified in two abrupt successions at the end of the Younger Dryas (9900 14C year BP) and especially in a second event during the early Holocene (8800 14C year BP). Dust discharge by northwesterly winds from Arabia exhibited a similar evolution, but followed an opposite course: high during the LGM with two primary sources-the central Arabian desert and the dry Persian Gulf region. Dust discharge from both regions reached a pronounced maximum at 15,000-13,000 14C year. At the end of this interval, however, the dust plumes from the Persian Gulf area ceased dramatically, whereas dust discharge from central Arabia decreased only slightly. Dust discharge from East Africa and the Red Sea increased synchronously with the two major events of southwest monsoon intensification as recorded in the nutrient content of surface waters. In addition to the tracers of past dust flux and surface water nutrient content, the geochemical multi-tracer approach provides information on the history of deep sea ventilation (Mo, S), which was much lower during the last glacial maximum than during the Holocene. The multi-tracer approach-i.e. a few sedimentological parameters plus a set of geochemical tracers widely available from various multi-element analysis techniques-is a highly applicable technique for studying the complex sedimentation patterns of an ocean basin, and, specifically in the case of the Arabian Sea, can even reveal the seasonal structure of climate change.

Database of the GLAMAP project

A uniform chronology for foraminifera-based sea surface temperature records has been established in more than 120 sediment cores obtained from the equatorial and eastern Atlantic up to the Arctic Ocean. The chronostratigraphy of the last 30,000 years is mainly based on published d18O records and 14C ages from accelerator mass spectrometry, converted into calendar-year ages. The high-precision age control provides the database necessary for the uniform reconstruction of the climate interval of the Last Glacial Maximum within the GLAMAP-2000 project.