Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis.

BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are the backbone of osteoarthritis pain management. We aimed to assess the effectiveness of different preparations and doses of NSAIDs on osteoarthritis pain in a network meta-analysis. METHODS For this network meta-analysis, we considered randomised trials comparing any of the following interventions: NSAIDs, paracetamol, or placebo, for the treatment of osteoarthritis pain. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the reference lists of relevant articles for trials published between Jan 1, 1980, and Feb 24, 2015, with at least 100 patients per group. The prespecified primary and secondary outcomes were pain and physical function, and were extracted in duplicate for up to seven timepoints after the start of treatment. We used an extension of multivariable Bayesian random effects models for mixed multiple treatment comparisons with a random effect at the level of trials. For the primary analysis, a random walk of first order was used to account for multiple follow-up outcome data within a trial. Preparations that used different total daily dose were considered separately in the analysis. To assess a potential dose-response relation, we used preparation-specific covariates assuming linearity on log relative dose. FINDINGS We identified 8973 manuscripts from our search, of which 74 randomised trials with a total of 58 556 patients were included in this analysis. 23 nodes concerning seven different NSAIDs or paracetamol with specific daily dose of administration or placebo were considered. All preparations, irrespective of dose, improved point estimates of pain symptoms when compared with placebo. For six interventions (diclofenac 150 mg/day, etoricoxib 30 mg/day, 60 mg/day, and 90 mg/day, and rofecoxib 25 mg/day and 50 mg/day), the probability that the difference to placebo is at or below a prespecified minimum clinically important effect for pain reduction (effect size [ES] -0·37) was at least 95%. Among maximally approved daily doses, diclofenac 150 mg/day (ES -0·57, 95% credibility interval [CrI] -0·69 to -0·46) and etoricoxib 60 mg/day (ES -0·58, -0·73 to -0·43) had the highest probability to be the best intervention, both with 100% probability to reach the minimum clinically important difference. Treatment effects increased as drug dose increased, but corresponding tests for a linear dose effect were significant only for celecoxib (p=0·030), diclofenac (p=0·031), and naproxen (p=0·026). We found no evidence that treatment effects varied over the duration of treatment. Model fit was good, and between-trial heterogeneity and inconsistency were low in all analyses. All trials were deemed to have a low risk of bias for blinding of patients. Effect estimates did not change in sensitivity analyses with two additional statistical models and accounting for methodological quality criteria in meta-regression analysis. INTERPRETATION On the basis of the available data, we see no role for single-agent paracetamol for the treatment of patients with osteoarthritis irrespective of dose. We provide sound evidence that diclofenac 150 mg/day is the most effective NSAID available at present, in terms of improving both pain and function. Nevertheless, in view of the safety profile of these drugs, physicians need to consider our results together with all known safety information when selecting the preparation and dose for individual patients. FUNDING Swiss National Science Foundation (grant number 405340-104762) and Arco Foundation, Switzerland.

Die Kupferkalkbrühe, ihre richtige Bereitung und ihre Anwendung in ziergärtnerischen Rosenanlagen

Von Fr. Richter

Clinical and economic outcomes of serious postoperative infections following resection of common respiratory and gastrointestinal solid tumors

Unlike infections occurring during periods of chemotherapy-induced neutropenia, postoperative infections in patients with solid malignancy remain largely understudied. The purpose of this population-based study was to evaluate the clinical and economic burden, as well as the relationship of hospital surgical volume and outcomes associated with serious postoperative infection (SPI) – i.e., bacteremia/sepsis, pneumonia, and wound infection – following resection of common solid tumors.^ From the Texas Discharge Data Research File, we identified all Texas residents who underwent resection of cancer of the lung, esophagus, stomach, pancreas, colon, or rectum between 2002 and 2006. From their billing records, we identified ICD-9 codes indicating SPI and also subsequent SPI-related readmissions occurring within 30 days of surgery. Random-effects logistic regression was used to calculate the impact of SPI on mortality, as well as the association between surgical volume and SPI, adjusting for case-mix, hospital characteristics, and clustering of multiple surgical admissions within the same patient and patients within the same hospital. Excess bed days and costs were calculated by subtracting values for patients without infections from those with infections computed using multilevel mixed-effects generalized linear model by fitting a gamma distribution to the data using log link.^ Serious postoperative infection occurred following 9.4% of the 37,582 eligible tumor resections and was independently associated with an 11-fold increase in the odds of in-hospital mortality (95% Confidence Interval [95% CI], 6.7-18.5, P < 0.001). Patients with SPI required 6.3 additional hospital days (95% CI, 6.1 - 6.5) at an incremental cost of $16,396 (95% CI, $15,927–$16,875). There was a significant trend toward lower overall rates of SPI with higher surgical volume (P=0.037). ^ Due to the substantial morbidity, mortality, and excess costs associated with SPI following solid tumor resections and given that, under current reimbursement practices, most of this heavy burden is borne by acute care providers, it is imperative for hospitals to identify more effective prophylactic measures, so that these potentially preventable infections and their associated expenditures can be averted. Additional volume-outcomes research is also needed to identify infection prevention processes that can be transferred from higher- to lower-volume providers.^

Prognosis of amyotrophic lateral sclerosis

Two cohorts of amyotrophic lateral sclerosis (ALS) patients were identified. One incidence-based cohort from Harris County, Texas with 97 cases, and the other a clinic referral series from an ALS clinic in Houston, Texas with 439 cases were followed-up to evaluate the prognosis of ALS. The overall Kaplan-Meier 3-year survival after diagnosis was similar, 0.287 for the incidence cohort and 0.313 for the referral cohort. However, the 5-year survival was much lower for the incidence cohort than the referral cohort (0.037 vs. 0.206). The large difference in 5-year survival was thought to be the results of a stronger unfavorable effect of the prognostic factors in the incidence cohort than in the referral cohort.^ Cohort-specific Weibull regression models were derived to evaluate the cohort-specific prognostic factors and survival probability with adjustment of certain prognostic factors.^ The major prognostic factors were: age at diagnosis, bulbar onset, black ethnicity, and positive family history of ALS in both cohorts. Female gender, simultaneous upper and lower extremities onset were specifically unfavorable factors in the incidence cohort. In the incidence cohort the prognosis was relatively favorable for cases with duration from onset to diagnosis longer than 4 months, however in the referral cohort the relatively favorable prognosis only occurred in cases with duration from onset to diagnosis 1 year or longer and was strongest in cases with duration 5 years and longer. Age at diagnosis modified the effect of bulbar onset in the incidence cohort but not in the referral cohort. The estimated survival with presence of an unfavorable prognostic factor identified in the incidence cohort was higher for the referral cohort than for the incidence cohort. Future studies are indicated to investigate the disease heterogeneity issue of ALS based on survival distribution of ALS. ^

Trastuzumab use and risk of congestive heart failure in older breast cancer patients

Trastuzumab is a humanized-monoclonal antibody, developed specifically for HER2-neu over-expressed breast cancer patients. Although highly effective and well tolerated, it was reported associated with Congestive Heart Failure (CHF) in clinical trial settings (up to 27%). This leaves a gap where, Trastuzumab-related CHF rate in general population, especially older breast cancer patients with long term treatment of Trastuzumab remains unknown. This thesis examined the rates and risk factors associated with Trastuzumab-related CHF in a large population of older breast cancer patients. A retrospective cohort study using the existing Surveillance, Epidemiology and End Results (SEER) and Medicare linked de-identified database was performed. Breast cancer patients ≥ 66 years old, stage I-IV, diagnosed in 1998-2007, fully covered by Medicare but no HMO within 1-year before and after first diagnosis month, received 1st chemotherapy no earlier than 30 days prior to diagnosis were selected as study cohort. The primary outcome of this study is a diagnosis of CHF after starting chemotherapy but none CHF claims on or before cancer diagnosis date. ICD-9 and HCPCS codes were used to pool the claims for Trastuzumab use, chemotherapy, comorbidities and CHF claims. Statistical analysis including comparison of characteristics, Kaplan-Meier survival estimates of CHF rates for long term follow up, and Multivariable Cox regression model using Trastuzumab as a time-dependent variable were performed. Out of 17,684 selected cohort, 2,037 (12%) received Trastuzumab. Among them, 35% (714 out of 2037) were diagnosed with CHF, compared to 31% (4784 of 15647) of CHF rate in other chemotherapy recipients (p<.0001). After 10 years of follow-up, 65% of Trastuzumab users developed CHF, compared to 47% in their counterparts. After adjusting for patient demographic, tumor and clinical characteristics, older breast cancer patients who used Trastuzumab showed a significantly higher risk in developing CHF than other chemotherapy recipients (HR 1.69, 95% CI 1.54 - 1.85). And this risk is increased along with the increment of age (p-value < .0001). Among Trastuzumab users, these covariates also significantly increased the risk of CHF: older age, stage IV, Non-Hispanic black race, unmarried, comorbidities, Anthracyclin use, Taxane use, and lower educational level. It is concluded that, Trastuzumab users in older breast cancer patients had 69% higher risk in developing CHF than non-Trastuzumab users, much higher than the 27% increase reported in younger clinical trial patients. Older age, Non-Hispanic black race, unmarried, comorbidity, combined use with Anthracycline or Taxane also significantly increase the risk of CHF development in older patients treated with Trastuzumab. ^

Baseline evaluation of environmental physical activity and nutrition support of Texas Medical Center hospital worksites

Background: Obesity is a major health problem in the United States that has reached epidemic proportions. With most U.S adults spending the majority of their waking hours at work, the influence of the workplace environment on obesity is gaining in importance. Recent research implicates worksites as providing an 'obesogenic' environment as they encourage overeating and reduce the opportunity for physical activity. Objective: The aim of this study is to describe the nutrition and physical activity environment of Texas Medical Center (TMC) hospitals participating in the Shape Up Houston evaluation study to develop a scoring system to quantify the environmental data collected using the Environmental Assessment Tool (EAT) survey and to assess the inter-observer reliability of using the EAT survey. Methods: A survey instrument that was adapted from the Environmental Assessment Tool (EAT) developed by Dejoy DM et al in 2008 to measure the hospital environmental support for nutrition and physical activity was used for this study. The inter-observer reliability of using the EAT survey was measured and total percent agreement scores were computed. Most responses on the EAT survey are dichotomous (Yes and No) and these responses were coded with a '0' for a 'no' response and a '1' for a 'yes' response. A summative scoring system was developed to quantify these responses. Each hospital was given a score for each scale and subscale on the EAT survey in addition to a total score. All analyses were conducted using Stata 11 software. Results: High inter-observer reliability is observed using EAT. The percentage agreement scores ranged from 94.4%–100%. Only 2 of the 5 hospitals had a fitness facility onsite and scores for exercise programs and outdoor facilities available for hospital employees ranged from 0–62% and 0–37.5%, respectively. The healthy eating percentage for hospital cafeterias range from 42%–92% across the different hospitals while the healthy vending scores were 0%–40%. The total TMC 'healthy hospital' score was 49%. Conclusion: The EAT survey is a reliable instrument for measuring the physical activity and nutrition support environment of hospital worksites. The study results showed a large variability among the TMC hospitals in the existing physical activity and nutrition support environment. This study proposes cost effective policy changes that can increase environmental support to healthy eating and active living among TMC hospital employees.^

Sr/Ca ratios of coccoliths from the Paleocene-Eocene Thermal Maximum

During the Paleocene-Eocene Thermal Maximum (PETM), rapid release of isotopically light C to the ocean-atmosphere system elevated the greenhouse effect and warmed temperatures by 5-7 °C for 105 yr. The response of the planktic ecosystems and productivity to the dramatic climate changes of the PETM may represent a significant feedback to the carbon cycle changes, but has been difficult to document. We examine Sr/Ca ratios in calcareous nannofossils in sediments spanning the PETM in three open ocean sites as a new approach to examine productivity and ecological shifts in calcifying plankton. The large heterogeneity in Sr/Ca among different nannofossil genera indicates that nannofossil Sr/Ca reflects primary productivity-driven geochemical signals and not diagenetic overprinting. Elevated Sr/Ca ratios in several genera and constant ratios in other genera suggest increased overall productivity in the Atlantic sector of the Southern Ocean during the PETM. Dominant nannofossil genera in tropical Atlantic and Pacific sites show Sr/Ca variations during the PETM which are comparable to background variability prior to the PETM. Despite acidification of the ocean there was not a productivity crisis among calcifying phytoplankton. We use the Pandora ocean box model to explore possible mechanisms for PETM productivity change. If independent proxy evidence for more stratified conditions in the Southern Ocean during the PETM is robust, then maintenance of stable or increased productivity there likely reflects increased nutrient inventories of the ocean. Increased nutrient inventories could have resulted from climatically enhanced weathering and would have important implications for burial rates of organic carbon and stabilization of climate and the carbon cycle.

Sedimentation rate calculations and isotopic analysis on sediment cores along the IODP Expedition 311 transect

The oceanographic and tectonic conditions of accretionary margins are well-suited for several potential processes governing methane generation, storage and release. To identify the relevant methane evolution pathways in the northern Cascadia accretionary margin, a four-site transect was drilled during Integrated Ocean Drilling Program Expedition 311. The d13C values of methane range from a minimum value of -82.2 per mil on an uplifted ridge of accreted sediment near the deformation front (Site U1326, 1829 mbsl, meters below sea level) to a maximum value of -39.5 per mil at the most landward location within an area of steep canyons near the shelf edge (Site U1329, 946 mbsl). An interpretation based solely on methane isotope values might conclude the 13C-enrichment of methane indicates a transition from microbially- to thermogenically-sourced methane. However, the co-existing CO2 exhibits a similar trend of 13C-enrichment along the transect with values ranging from -22.5 per mil to +25.7 per mil. The magnitude of the carbon isotope separation between methane and CO2 (Ec = 63.8 ± 5.8) is consistent with isotope fractionation during microbially mediated carbonate reduction. These results, in conjunction with a transect-wide gaseous hydrocarbon content composed of > 99.8% (by volume) methane and uniform dDCH4 values (-172 per mil ± 8) that are distinct from thermogenic methane at a seep located 60 km from the Expedition 311 transect, suggest microbial CO2 reduction is the predominant methane source at all investigated sites. The magnitude of the intra-site downhole 13C-enrichment of CO2 within the accreted ridge (Site U1326) and a slope basin nearest the deformation front (Site U1325, 2195 mbsl) is ~ 5 per mil. At the mid-slope site (Site U1327, 1304 mbsl) the downhole 13C-enrichment of the CO2 is ~ 25 per mil and increases to ~ 40 per mil at the near-shelf edge Site U1329. This isotope fractionation pattern is indicative of more extensive diagenetic alteration at sites with greater 13C-enrichment. The magnitude of the 13C-enrichment of CO2 correlates with decreasing sedimentation rates and a diminishing occurrence of stratigraphic gas hydrate. We suggest the decreasing sedimentation rates increase the exposure time of sedimentary organic matter to aerobic and anaerobic degradation, during burial, thereby reducing the availability of metabolizable organic matter available for methane production. This process is reflected in the occurrence and distribution of gas hydrate within the northern Cascadia margin accretionary prism. Our observations are relevant for evaluating methane production and the occurrence of stratigraphic gas hydrate within other convergent margins.

De territorialidades ensayísticas: (re) definiciones identitarias de Misiones. 16H376

En la presente investigación se pretende explorar desde la clave ensayística las producciones de los escritores fundantes de Misiones, indagar sus discursos emanados de cruces genéricos en constante ebullición con una impronta literaria difusa, lo que permite de esta manera la construcción de una identidad inclusiva de lo diverso. En tal sentido creemos que la dinámica ensayística combina la crítica y la factibilidad interpretativa puesta en valor y el despliegue de sentidos. Así concentra y expande el ciclo infinito del leer y del escribir, del nombrar y el interpretar, del mostrar y el demostrar, del explicar y el imaginar, reactualizando los procesos de crítica y elucidación de los textos de la cultura. El ensayo constituye la forma por excelencia del pensamiento en lo que éste contiene de indeterminado, de transcurso hacia un objetivo establecido. Aquí las pasiones convergen en el saber, irrumpe la subjetividad y el interés por lo imaginativo. De este modo, se presenta como una confederación de géneros, ya que confluyen en él la didáctica, la poesía, la oratoria, lo lúdico, la destreza y la impronta expresiva que potencia el frenesí de pensamientos. Es pertinente aclarar que la investigación se inscribe en el marco del PROGRAMA INVESTIGACIONES INTERDISPLINARIASSOBRE REGIONES DE FRONTERA ESTADO, SISTEMAS SOCIOCULTURALES Y TERRITORIOS" 2013-2015.