Background Intensive hemodialysis (HD) is characterized by increased frequency and/or session length compared to conventional HD. Previous analyses from Australia and New Zealand did not suggest ...benefit with intensive HD, although recent research suggests that relationships have changed. We present updated analyses. Study Design Observational cohort study using marginal structural modeling to adjust for changes in renal replacement modality and time-varying medical comorbid conditions. Setting & Participants Adults initiating renal replacement therapy since March 31, 1996, followed up through December 31, 2012; this analysis included 40,842 patients over 2,187,689 patient-months. Predictor Time-varying renal replacement modality: conventional facility HD (≤3 times per week, ≤6 hours per session), quasi-intensive facility HD (between conventional and intensive), intensive facility HD (≥5 times per week, any hours per session), conventional home HD, quasi-intensive home HD, intensive home HD, peritoneal dialysis, deceased donor kidney transplantation, and living donor kidney transplantation. Outcomes Patient mortality, with a 3-month lag in primary analyses and 6- and 12-month lags in sensitivity analyses. Results Conventional facility HD was the reference group. Conventional home HD had a similar mortality risk. For quasi-intensive home HD, mortality risk was lower (HR, 0.56; 95% CI, 0.44-0.73). For intensive home HD, mortality risk was nonsignificantly lower in primary analyses and significantly lower using a 6-month lag (HR, 0.41; 95% CI, 0.20-0.85), but not using a 12-month lag. For quasi-intensive facility HD, mortality risk was nonsignificantly lower in primary analyses, although significantly lower using 6- (HR, 0.41; 95% CI, 0.20-0.85) and 12-month lags (HR, 0.59; 95% CI, 0.44-0.80). Mortality risk was similar between intensive and conventional facility HD. For peritoneal dialysis, mortality risk was greater than for conventional facility HD (HR, 1.07; 95% CI, 1.03-1.12). Kidney transplantation had the lowest mortality risk. Limitations Potential residual confounding from limited collection of comorbid condition, socioeconomic, and medication data. Conclusions There is an emerging HD dose-effect in Australia and New Zealand, with lower mortality risks associated with some of the more intensive HD regimens in these countries.
Sown wildflower areas are increasingly recommended as an agri-environmental intervention measure, but evidence for their success is limited to particular insect groups or hampered by the challenges ...of establishing seed mixes and maintaining flower abundance over time. We conducted a replicated experiment to establish wildflower areas to support insect pollinators in apple orchards. Over three years, and across 23 commercial UK orchards with and without sown wildflowers, we conducted 828 transect surveys across various non-crop habitats. We found that the abundance of flower-visiting solitary bees, bumblebees, honeybees, and beetles was increased in sown wildflower areas, compared with existing non-crop habitats in control orchards, from the second year following floral establishment. Abundance of hoverflies and other non-syrphid flies was increased in wildflower areas from the first year. Beyond the effect of wildflower areas, solitary bee abundance was also positively related to levels of floral cover in other local habitats within orchards, but neither local nor wider landscape-scale context affected abundance of other studied insect taxa within study orchards. There was a change in plant community composition on the sown wildflower areas between years, and in patterns of flowering within and between years, showing a succession from unsown weedy species towards a dominance of sown species over time. We discuss how the successful establishment of sown wildflower areas and delivery of benefits for different insect taxa relies on appropriate and reactive management practices as a key component of any such agri-environment scheme.
Zircon megacrysts are locally abundant in 1–40 cm-thick orthopyroxenite veins within peridotite host rocks in the Archaean Lewisian gneiss complex from NW Scotland. The veins formed by metasomatic ...interaction between the ultramafic host and Si-rich melts are derived from partial melting of the adjacent granulite-facies orthogneisses. The interaction produced abundant orthopyroxene and, within the thicker veins, phlogopite, pargasite and feldspathic bearing assemblages. Two generations of zircon are present with up to 1 cm megacrystic zircon and a later smaller equant population located around the megacryst margins. Patterns of zoning, rare earth element abundance and oxygen isotopic compositions indicate that the megacrysts crystallized from crustal melts, whereas the equant zircon represents new neocryst growth and partial replacement of the megacryst zircon within the ultramafic host. Both zircon types have U–Pb ages of ca. 2464 Ma, broadly contemporaneous with granulite-facies events in the adjacent gneisses. Zircon megacrysts locally form > 10% of the assemblage and may be associated to zones of localized nucleation or physically concentrated during movement of the siliceous melts. Their unusual size is linked to the suppression of zircon nucleation and increased Zr solubility in the Si-undersaturated melts. The metasomatism between crustal melts and peridotite may represent an analog for processes in the mantle wedge above subducting slabs. As such, the crystallization of abundant zircon in ultramafic host rocks has implications for geochemistry of melts generated in the mantle and the widely reported depletion of high field strength elements in arc magmas.
Armillaria altimontana is a fungus (Basidiomycota, Agaricomycetes, Agaricales, and Physalacriaceae) that is generally considered as a weak/opportunistic pathogen or saprophyte on many tree hosts. It ...widely occurs across the northwestern USA to southern British Columbia, Canada, but relatively little is known about its ecological role in the diverse forest ecosystems where it occurs. This review summarizes the biology and ecology of A. altimontana, including its identification, life cycle, distribution, host associations, and bioclimatic models under climate change.
Background
Asthma remission has emerged as a potential treatment goal. This study evaluated the effectiveness of two biologics (mepolizumab/omalizumab) in achieving asthma remission.
Methods
This ...observational study included 453 severe asthma patients (41% male; mean age ± SD 55.7 ± 14.7 years) from two real‐world drug registries: the Australian Mepolizumab Registry and the Australian Xolair Registry. The composite outcome clinical remission was defined as zero exacerbations and zero oral corticosteroids during the previous 6 months assessed at 12 months and 5‐item Asthma Control Questionnaire (ACQ‐5) ≤1 at 12 months. We also assessed clinical remission plus optimization (post‐bronchodilator FEV1 ≥80%) or stabilization (post‐bronchodilator FEV1 not greater than 5% decline from baseline) of lung function at 12 months. Sensitivity analyses explored various cut‐offs of ACQ‐5/FEV1 scores. The predictors of clinical remission were identified.
Results
29.3% (73/249) of AMR and 22.8% (37/162) of AXR cohort met the criteria for clinical remission. When lung function criteria were added, the remission rates were reduced to 25.2% and 19.1%, respectively. Sensitivity analyses identified that the remission rate ranged between 18.1% and 34.9% in the AMR cohort and 10.6% and 27.2% in the AXR cohort. Better lung function, lower body mass index, mild disease and absence of comorbidities such as obesity, depression and osteoporosis predicted the odds of achieving clinical remission.
Conclusion
Biologic treatment with mepolizumab or omalizumab for severe asthma‐induced asthma remission in a subgroup of patients. Remission on treatment may be an achievable treatment target and future studies should consider remission as an outcome measure.
The effectiveness of mepolizumab and omalizumab in achieving asthma remission was evaluated in an observational study. The basic definition consists of no asthma attack, no oral corticosteroids (OCS) use and ACQ5 ≤1 at 12 ‐months. We also evaluated various definitions and asthma control questionnaire (ACQ) cut‐offs in sensitivity analyses. The observed remission rate ranged between 18.1% and 34.9% in mepolizumab and 10.6% and 27.2% in omalizumab cohorts.Abbreviations: CR, clinical remission; ACQ, asthma control questionnaire; OCS, oral corticosteroids; LF, lung function.
We planned to systematically review the efficacy of sargramostim (granulocyte colony stimulating factor GM-CSF) for remission induction in patients with Crohn's disease (CD).
A literature search to ...April 2011 was performed to identify all randomized trials studying sargramostim in patients with CD. The Cochrane risk of bias tool was used to evaluate study quality and the GRADE criteria were utilized to assess the overall quality of the evidence.
Three randomized studies (total 537 patients) were identified. The risk of bias was low for the three included studies. There was no statistically significant difference in the proportion of patients who achieved clinical remission (GM-CSF 25.3%; placebo 17.5%; relative risk RR 1.67; 95% confidence interval CI 0.80-3.50; P = 0.17), or 100-point clinical response (GM-CSF 38.3%; placebo 24.8%; RR 1.71 95% CI 0.98-2.97; P = 0.06). There was no statistically significant difference in the proportion of patients (GM-CSF 95.8%; placebo 89.3%) who experienced adverse events (RR 1.07; 95% CI 0.99-1.16; P = 0.08), or serious adverse events (GM-CSF 12.0% vs. placebo 4.8%; RR 2.21; 95% CI 0.84-5.81; P = 0.11).
Sargramostim does not appear to be more effective than placebo for induction of clinical remission or improvement in active CD. However, the GRADE analysis indicates that the overall quality of the evidence for the primary and secondary outcomes was low due to sparse data and heterogeneity, indicating that further research likely would have a significant impact on the effect estimates.
Interventions for treating lymphocytic colitis Chande, Nilesh; Al Yatama, Noor; Bhanji, Tania ...
Cochrane database of systematic reviews,
07/2017, Volume:
2017, Issue:
11
Journal Article
Peer reviewed
Open access
Background
Lymphocytic colitis is a cause of chronic diarrhea. It is a subtype of microscopic colitis characterized by chronic, watery, non‐bloody diarrhea and normal endoscopic and radiologic ...findings. The etiology of this disorder is unknown.Therapy is based mainly on case series and uncontrolled trials, or by extrapolation of data for treating collagenous colitis, a related disorder. This review is an update of a previously published Cochrane review.
Objectives
To evaluate the efficacy and safety of treatments for clinically active lymphocytic colitis.
Search methods
The MEDLINE, PUBMED and EMBASE databases were searched from inception to 11 August 2016 to identify relevant papers. Manual searches from the references of included studies and relevant review articles were performed.
s from major gastroenterological meetings were also searched to identify research submitted in form only. The trial registry web site www.ClinicalTrials.gov was searched to identify registered but unpublished trials. Finally, the Cochrane Central Register of Controlled Trials and the Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group Specialized Trials Register were searched for other studies.
Selection criteria
Randomized controlled trials assessing medical therapy for patients with biopsy‐proven lymphocytic colitis were considered for inclusion
Data collection and analysis
Data was independently extracted by at least two authors. Any disagreements were resolved by consensus. Data were analyzed on an intention‐to‐treat (ITT) basis. The primary outcome was clinical response as defined by the included studies. Secondary outcome measures included histological response as defined by the included studies, quality of life as measured by a validated instrument and the occurrence of adverse events. Risk ratios (RR) and 95% confidence intervals (CI) were calculated for dichotomous outcomes. The methodological quality of included studies was evaluated using the Cochrane risk of bias tool. The overall quality of the evidence supporting the primary outcome and selected secondary outcomes was assessed using the GRADE criteria. Data were combined for analysis if they assessed the same treatments. Dichotomous data were combined using a pooled RR along with corresponding 95% CI. A fixed‐effect model was used for the pooled analysis.
Main results
Five RCTs (149 participants) met the inclusion criteria. These studies assessed bismuth subsalicylate versus placebo, budesonide versus placebo, mesalazine versus mesalazine plus cholestyramine and beclometasone dipropionate versus mesalazine. The study which assessed mesalazine versus mesalazine plus cholestyramine and the study which assessed beclometasone dipropionate versus mesalazine were judged to be at high risk of bias due to lack of blinding. The study which compared bismuth subsalicylate versus us placebo was judged as low quality due to a very small sample size and limited data. The other 3 studies were judged to be at low risk of bias. Budesonide (9 mg/day for 6 to 8 weeks) was significantly more effective than placebo for induction of clinical and histological response. Clinical response was noted in 88% of budesonide patients compared to 38% of placebo patients (2 studies; 57 participants; RR 2.03, 95% CI 1.25 to 3.33; GRADE = low). Histological response was noted in 78% of budesonide patients compared to 33% of placebo patients (2 studies; 39 patients; RR 2.44, 95% CI 1.13 to 5.28; GRADE = low). Forty‐one patients were enrolled in the study assessing mesalazine (2.4 g/day) versus mesalazine plus cholestyramine (4 g/day). Clinical response was noted in 85% of patients in the mesalazine group compared to 86% of patients in the mesalazine plus cholestyramine group (RR 0.99, 95% CI 0.77 to 1.28; GRADE = low). Five patients were enrolled in the trial studying bismuth subsalicylate (nine 262 mg tablets daily for 8 weeks versus placebo). There were no differences in clinical (P=0.10) or histological responses (P=0.71) in patients treated with bismuth subsalicylate compared with placebo (GRADE = very low). Forty‐six patients were enrolled in the trial studying beclometasone dipropionate (5 mg/day or 10 mg/day) versus mesalazine (2.4 g/day). There were no differences in clinical remission at 8 weeks (RR 0.97; 95% CI 0.75 to 1.24; GRADE = low) and 12 months of treatment (RR 1.29; 95% CI 0.40 to 4.18; GRADE = very low). Although patients receiving beclometasone dipropionate (84%) and mesalazine (86%) achieved clinical remission at 8 weeks, it was not maintained at 12 months (26% and 20%, respectively). Adverse events reported in the budesonide studies include nausea, vomiting, neck pain, abdominal pain, hyperhidrosis and headache. Nausea and skin rash were reported as adverse events in the mesalazine study. Adverse events in the beclometasone dipropionate trial include nausea, sleepiness and change of mood. No adverse events were reported in the bismuth subsalicylate study.
Authors' conclusions
Low quality evidence suggests that budesonide may be effective for the treatment of active lymphocytic colitis. This benefit needs to be confirmed by a large placebo ‐controlled trial. Low quality evidence also suggests that mesalazine with or without cholestyramine and beclometasone dipropionate may be effective for the treatment of lymphocytic colitis, however this needs to be confirmed by large placebo‐controlled studies. No conclusions can be made regarding bismuth subsalicylate due to the very small number of patients in the study, Further trials studying interventions for lymphocytic colitis are warranted.
Summary
Background
The optimal ulcerative colitis biopsy protocol is unclear.
Aim
To evaluate the number of biopsies required to accurately assess microscopic disease activity in ulcerative colitis
...Methods
Biopsies from patients with ≥4 rectosigmoid samples, and clinical and endoscopic data, were retrospectively obtained from a prospective biobank. Histology and endoscopic videos were read blindly. A 4‐biopsy Robarts Histopathology Index (RHI) reference score, consisting of the worst item‐level ratings from four biopsies, was compared to 1‐, 2‐ and 3‐biopsy estimates. Agreement was determined using bivariate errors‐in‐variable regression analysis (acceptance interval: ±8.25). Endoscopic activity and disease location subgroup analyses were also performed.
Results
Forty‐six patients had ≥4 rectosigmoid biopsies available (N = 287). The 2‐biopsy (tolerance interval: −7.66, 4.79) and 3‐biopsy (tolerance interval: −4.86, 3.46) RHI scores demonstrated acceptable agreement with 4‐biopsy scores. One‐biopsy scores demonstrated unacceptable agreement (tolerance interval: −13.99, 7.78). Mean RHI scores using the 2‐, 3‐ and 4‐biopsy approaches were similar (6.1 ± 9.6 P = 0.36; 6.8 ± 10.5, P = 0.7; 7.5 ± 11.2), whereas the 1‐biopsy estimate was lower (4.4 ± 8.1, P = 0.06). Histological remission rates were identical for the 2‐, 3‐ and 4‐biopsy methods (65.2%, P = 1.0). Subgroup analysis demonstrated that three biopsies were required in patients with endoscopically active disease. Sampling additional colonic locations yielded lower histological remission rates compared to rectosigmoid sampling alone (33.3% vs 61.9%, P = 0.1).
Conclusions
A minimum of two — conservatively, three — biopsies are required to reliably assess disease activity in a single colonic segment using the RHI. Further studies are needed of endoscopically active patients and sampling locations. These results have implications for biopsy strategies in clinical trials and practice.
Cell death was examined by studying the spinal cords of rats subjected to traumatic insults of mild to moderate severity. Within minutes after mild weight drop impact (a 10 gm weight falling 6.25 ...mm), neurons in the immediate impact area showed a loss of cytoplasmic Nissl substances. Over the next 7 d, this lesion area expanded and cavitated. Terminal deoxynucleotidyl transferase (TdT)-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL)-positive neurons were noted primarily restricted to the gross lesion area 4-24 hr after injury, with a maximum presence at 8 hr after injury. TUNEL-positive glia were present at all stages studied between 4 hr and 14 d, with a maximum presence within the lesion area 24 hr after injury. However 7 d after injury, a second wave of TUNEL-positive glial cells was noted in the white matter peripheral to the lesion and extending at least several millimeters away from the lesion center. The suggestion of apoptosis was supported by electron microscopy, as well as by nuclear staining with Hoechst 33342 dye, and by examination of DNA prepared from the lesion site. Furthermore, repeated intraperitoneal injections of cycloheximide, beginning immediately after a 12.5 mm weight drop insult, produced a substantial reduction in histological evidence of cord damage and in motor dysfunction assessed 4 weeks later. Present data support the hypothesis that apoptosis dependent on active protein synthesis contributes to the neuronal and glial cell death, as well as to the neurological dysfunction, induced by mild-to-moderate severity traumatic insults to the rat spinal cord.
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