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Pip install -upgrade -r requirements.txt -target=$HOME/ConductorDev Install development dependencies pip install -r requirements_dev.txtīuild and install from this directory into to a convenient location for testing. Set up a clean virtual envirionment with Python 2.7 for development (optional). To set up a render, choose Conductor->Submitter->Create from the Conductor menu.įor detailed help, checkout the tutorial and reference documentation. Go to Conductor->About to check the version and other info. Open the Plugin Manager and load Conductor.py. NOTE An alternative is to install from the Plugins page in the Conductor Companion app Usage python ~/Conductor/ciomaya/post_install.py pip install -upgrade -force-reinstall ciomaya = 0.1.0 -target = $HOME/Conductor To install a specific version, for example 0.1.0. pip install -upgrade ciomaya -target = $HOME/Conductor Supports Maya versions from 2017 to 2023. In V-Ray, you can actually output hundreds of render elements, each with denoise selected, and they will all represent their proper contribution of the denoised image.Maya plugin node to manage submissions to Conductor's cloud service. In this example, we show a complex scene with a large number of render elements, including all the standard passes as well as several light selects. And you don’t get artifacts such as edge issues. You may still see some level of noise in each render element, but when you recomposite the image back to beauty, the image integrity is preserved. V-Ray considers all the render elements when denoising and each render element only represents its portion of the denoised image. What's interesting is that V-Ray does not denoise each render element separately. What this means is that if you select the VRayDenoiser render element, each of the other render elements that have the denoiser option chosen will also be denoised. In V-Ray Next, users will notice that nearly every render element has an option called denoise. Those differences can result in swimming patterns as you go from frame to frame. As each image is different, the denoising of each image will also be different. If you are rendering an animation, this means that every image will be denoised separately. When you denoise an image, the algorithm tries to detect noise and smooth out part of that image through filtering and blurring, while still preserving edge integrity. Let me explain how the new render element denoiser in V-Ray Next eliminates this problem by maintaining the correct contribution of the complete denoised image for each render element. If each render element is denoised on its own, then your recomposite back to a beauty image could have a lot of artifacts. That would mean that all the render elements would also need to be denoised. Now imagine that you want to use the denoised image as the beauty. One issue that can come up is that each render element has to represent an exact contribution of the original beauty image or artifacts can appear, especially near edges. The challenge then becomes to recomposite the beauty image using the individual elements. It’s common to split out many aspects of the render into different parts like specular, reflection, reflection filter, diffuse filter, lighting, and global illumination. In the visual effects world, artists will output a large number of render elements to allow for adjustments in compositing. But it does have some limitations that keep it from being the best solution for final renderings. Because it gives users a near real-time denoised solution, it’s a great option for lighting and scene composition. In an earlier blog post, we explained the pros and cons of the new NVIDIA AI Denoiser that’s in V-Ray Next. And rarely does one solution fit all cases. Denoising is a relatively complex problem. Frank Oz was offered the part, but since he disliked performing full-body characters, he turned down the job. Pierre, the costume was built for Jim Henson to perform, but when Henson tried it on, Kermit Love, who had built the costume, did not think that Henson was walking like a bird is supposed to walk, and so Henson decided not to perform Big Bird. According to The Story of Jim Henson by Stephanie St. He also performed Big Bird when he appeared on The Ed Sullivan Show in 1969 and on Hollywood Squares in the 1970s. Spinney was sick during the taping of a few first-season episodes, so Daniel Seagren performed Big Bird in those episodes. Vogel became Big Bird's primary performer after Spinney's retirement. The apprentices included both Rick Lyon in the opening theme song of the show's 33rd season, and later Matt Vogel in the show's "Journey to Ernie" segment. In the later years of Spinney's career, the show gradually started training new performers to play Big Bird. Performing Big Bird īig Bird was performed by Caroll Spinney starting in 1969. In 2000, Big Bird was named a Living Legend by the United States Library of Congress. Matt Vogel began as an understudy in 1996 before becoming the character's full-time performer in 2018. In Season 46, Big Bird's large nest is now sitting within a small, furnished maple tree, and is no longer hidden by used construction doors.Ĭaroll Spinney performed Big Bird from 1969 to 2018. He lives in a large nest behind the 123 Sesame Street brownstone and right next to Oscar the Grouch's trash can. Despite this wide array of talents, he is prone to frequent misunderstandings, on one occasion even singing the alphabet as one long word (from the song called " ABC-DEF-GHI," pronounced / æ b k ə d ɛ f ɡ iː dʒ ɛ k ə l m ɪ n ɒ p k w ər ˈ s t uː v w ɪ k s ɪ z/), pondering what it could mean. An eight-foot two-inch (249 cm) tall bright yellow anthropomorphic bird, he can roller skate, ice skate, dance, swim, sing, write poetry, draw, and ride a unicycle. Turkey, feather face and others, by Oscar the Grouchīig Bird is a Muppet character designed by Jim Henson and built by Kermit Love for the long-running children's television show Sesame Street. Many come with slotted grooves that hold prints or framed items at the perfect angle.Grandsonny, a nickname given to him by his Granny Bird Putting artwork, cherished items, plants, photography and trophies on display is easy with picture ledges that can be combined any way you choose for a stunning home gallery effect. Go with the modern, pop-art like colorful trees that double as growth charts for your kids, or classic illustrations of ferns and flowers. Wall decals and stickers are ready to help you add color and cool lines to any space, in any room in minutes. Combine a fun illustrative style of some cards with statement pieces that can literally say what should set the mood in a glowing neon font. Since they’re smaller, it’s easy to turn any stretch of wall into a mini art gallery. Art cardsĬreate fun themes and statements with art cards that will bring out your creativity. Put photos of rustic countrysides on display or the modern look of playfully patterned geometric shapes. Art postersĮxpress your style with art posters in all sizes that showcase the classic look of still-life paintings. Let colorful flowers tower over miniature animals or find other fun, whimsical illustrations. Choose from exotic travel locales or industrial streetscapes and aerial photo maps from your favorite city. Wall artĪrt is subjective, so put something up on the wall that speaks to you while making any room feel different in the process. Photo framesĪvailable in a wide range of colors and sizes, our frames range from classic to modern looks which are ready to help you decorate with the photos you love. Add wedding, vacation or kids photos and you’ve got a stunning display that catches the eye while helping you tell a story close to you and your loved ones. The varying assortment of collage frames-from same size to big and small frames-are like a staggered expression of modern art themselves as the combined frames jut off at different angles while forming a whole. There are so many ways to make any room cozier and more your own. Draw the eyes by creating stunning focal points with wall decor that can add depth to any room. Has your home office felt a little ho-hum or did you overlook decorating the living room or basement? Then make boring rooms new again by turning them into something truly special with the endless possibilities in wall decorations that make a statement while reconfiguring the look, feel and mood. Whether moving to a new home or going through renovations, once you’ve settled on flooring, furniture and anything else you think you may need in a given room there could still be something else missing: your signature sense of style. Exact cause is unknown one school of thought states it to be a manifestation of peripheral vitreous traction while one believes it to be simply an abnormal reflex from a structurally normal VR interface.Characteristics: Whiter than the retina in white with pressure and the choroidal markings are almost obscured, found in post-equitorial region at the base of the vitreous and ora serrata, whiteness further accentuated with scleral depression, margins are sharply demarcated from normal retina.Prevalence: found in up to 30% of normal eyes, often bilateral, more frequently diagnosed in younger patients, may be associated with longer axial length.Definition: Distinctive white appearance of the peripheral retina without indentation and without mechanical stimulus.Treatment: should be treated when patients are symptomatic, or there is progressive retinal detachment threatening the macula.Diagnosis: OCT findings include intraretinal hyporeflective cavities with destruction and thickening of the RPE.Primary cause of retinal detachment in 0.05-2.5% of cases.Complications: may involve posterior pole, may lead to retinal detachment.Immobile with movement of eye and produces an absolute field defect.Characteristics: Lesion is a bullous elevation of peripheral retina, found in temporal segment.Prevalence: found in 2-7% of the general population, more common in patients 40 years and older and in hyperopic eyes.Definition: senile retinoschisis (SR) is the splitting of layers of the neurosensory retina by thick fluid.Intra-Retinal Degenerations Senile Retinoschisis Therefore, OCT should be utilized in the initial diagnosis, treatment, and follow-up for peripheral retinal degenerations. Peripheral OCT may further aid in differentiation between types of peripheral retinal degeneration as well associated complications including subclinical retinal detachment, retinoschisis, retinal tears and vitreoretinal adhesions or tractions. Such detail includes the structure, shape and depth of retinal degenerations. Optical coherence tomography (OCT) has been shown to greatly benefit in the diagnosis of peripheral retinal degenerations by characterizing structural elements. Chorioretinal degenerations: paving stone degeneration and peripheral retinal drusen.Vitreoretinal degenerations: lattice degeneration, snail-track degeneration, retinal tufts, and peripheral retinal breaks.Intra-retinal Degenerations: senile retinoschisis, white-without-pressure, white-with-pressure, dark-without-pressure, peripheral cystoid degeneration, snowflake degeneration, and pearl degeneration.The following are the commonly used classifications of peripheral retinal degenerations based upon depth of retinal changes observed on optical coherence tomography (OCT): Depth of retinal changes- intraretinal, retinal, vitreoretinal, or chorioretinal.Pathomorphology- trophic, tractional, atrophic, or combined.Location- equatorial, peripheral, or combined.Peripheral retinal degenerations are classified according to the following criteria: 1 Classification of Peripheral Retinal DegenerationsĬlassification of Peripheral Retinal Degenerations.If you have a history of lattice degeneration, you should be aware of the symptoms of retinal tears and detachment. Preventive treatment of lattice degeneration has not been shown to prevent retinal detachment, but lattice degeneration should be monitored. Lattice degeneration can sometimes cause retinal detachments when holes or tears in the lattice formation permit vitreous fluid to get under the retina.įortunately, most people with lattice degeneration do not develop a retinal detachment. If part of the vitreous sac becomes detached from the retina, the friction and pulling where it is still attached can create a tear in the retina. This pulling weakens the retina and creates lattice lesions that look like white crisscrossing lines on the retina. In lattice degeneration, there are places where the sac is strongly attached to the retina and pulls on it. As one ages, the vitreous takes on a more fluid consistency and the sac sometimes separates from the retina. The vitreous, a clear gel-like substance that fills the inside of the eye, is contained in a sac loosely attached to the retina. At Little Corona del Mar Beach, continue southeast (you can reach another sea cave by heading right or northwest if tides are exceptionally low and you time your trip right, you may be able to visit both this cave and Little Treasure Cove). As with other beachside hikes that involve rock scrambling, the challenge here is not in the minimal elevation gain or distance but rather the potentially hazardous terrain.įrom the corner of Ocean and Poppy, head down to the beach on the paved walkway, passing some restrooms. If tides are low – below zero – the rock scrambling required to reach the cave from the northwest is minimal, although caution should still be exercised. (Parking is free, too – although limited). While the most common way to visit the cave is from Crystal Cove’s main entrance, hiking from Little Corona del Mar Beach provides opportunities to visit three other caves. The cave at Little Treasure Cove sits at the northwestern end of Crystal Cove State Park. More information: Video with drone footage of the area here.Restrooms: Near the beginning of the hike.Water: Fountains at the start of the hike and at restrooms.Cell phone reception: Good at the start of the hike weak to none for most of the route.Dogs: Not allowed (allowed on leash at Corona Del Mar beach only).Best season: Year round during low tide.Agency: City of Newport Beach/ Crystal Cove State Park.If you are coming via Pacific Coast Highway, the turnoff for Poppy Drive is about 9 miles southeast of Huntington Beach and 13 miles northwest of Dana Point. Park where available near the corner of Poppy and Ocean, where the walkway to the beach begins. Turn right and follow Poppy Drive to its end at Ocean Blvd. Turn left onto Pacific Coast Highway and go 0.9 mile to Poppy Drive. From the 73 Freeway, take the MacArthur exit and head south for 2.6 miles. The flipside of how smoothly Going Medieval’s little settlements run themselves, however, is that I found the game almost devoid of challenge. But the fact that my instincts translated across so effortlessly shows what a robust job Foxy Voxel have done. It helps that I already know RimWorld back to front, I suppose. I was impressed with how rarely my little yokels acted with disastrous lack of foresight, and how little time I had to spend either micromanaging them, or working out why the hell supposedly basic things weren’t happening. RimWorld didn't have modelled seasonal changes for quite a while into its early access period, but it's already implemented in Going Medieval and looking great. Developers Foxy Voxel have cherry-picked bits and bobs from all over that game’s lifespan to populate their day one feature list, while also building in a bunch of the quality of life fixes which RimWorld dev Tynan Sylvester patched in as he went along. But to be even more fair, it owes that head start almost entirely to RimWorld. Doesn't that make you feel good?Īlso, to be fair, while Going Medieval is still in that fairly barren, aimless state which all early access sandbox games are born into, it’s a much more solid play than RimWorld was at the same point in its lifecycle. Look at this lovely cellar full of barrels and that. I’m almost embarrassed by how huge a difference it makes to me, to be able to build proper halls with thatched roofs, stone keeps looming over forests, and cellars packed with smoked meats and hay. Just imagine RimWorld, but with lutes and stuff, and you can build things on top of each other. What’s it like to play? As I said, like RimWorld. Through a combination of luck and judgement - and assembling the triforce of colony simulation, multiple z-layers and an easily comprehensible interface - Going Medieval has shot the Steam Knight right in the bonce. But they were either shit, or abandoned, or simply unlucky, wizening instantly into skeletons under the pitiless gaze of the immortal Steam Knight. I know other games have reached for this particular grail, over the years. What about 2010’s Bum Forts, Nate? Fuck’s sake, man, how can you ignore 2014’s Skyscrapers Of The Dogmen? Actually, Nate, I think you’ll find 2012’s criminally overlooked Goblin Slumlord did both things magnificently. As such, the world had no choice but to wait another five years to get it a man that could do both. Dwarf Fortress had three dimensions but wasn’t accessible RimWorld was the other way round. And despite all the marvellous complexity it would go on to acquire in other respects, its flatness would remain hardwired into the foundations of the game. I particularly like the fact that research is conducted by people actually writing scrolls, which then need to be stored somewhere - eventually, you find yourself inventing the library, which is immensely satisfying.īut RimWorld, for all its accessibility, had taken the step back into two dimensions. Indeed, so were all of the rest of its pleasures, until RimWorld appeared in 2016 I know I'm stressing the point that Going Medieval doesn't add much to the RimWorld formula besides the obvious, but it does have some original flourishes. Even so, to the vast majority of humanity still stuck on the steep side of the famous Dwarf Fortress learning curve, the pleasure was entirely inaccessible. It gained its so-called z-levels at the end of 2007, and the effect was transformative. Dwarf Fortress, the game which RimWorld itself took inspiration from, was originally played in a flat, one-layer world. Honestly, it spanners my brain to think that it has taken this long. That’s Going Medieval’s killer feature, and I’m saying that with a completely straight face. You can build multi-storey constructions. But the wooden beam unlocks the singular piece of magic which marks Going Medieval out as a competitor to the game it otherwise imitates: the third dimension. It’s nothing much by itself just a fat stick, really, which spans the gap between two facing walls. The wooden beam is one of the first technologies you can research in the game. After a moment or two to get used to the UI, I was playing my first game on autopilot, and all it really did for me was make me want to play RimWorld. As in, identical, save for a medieval setting and a ton of missing features. But pre-alpha colony sims are like the planktonic larvae of crabs - there’s millions of them, and most of them get eaten by fish, so I don’t tend to pay attention to them until they’re big enough to nip my fingers.Įven when Going Medieval did scuttle into early access at the start of the month, I have to say it seemed a blunt-clawed specimen. It’s funny, isn’t it, the things which make you fall in love with a game? I’d first heard of early access colony sim Going Medieval two years ago, at the very start of its development. 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Or more of your copyrights, please notify us by providing a written notice (“Infringement Notice”) containing If you believe that content available by means of the Website (as defined in our Terms of Service) infringes one Now that we calculated the length of D1, D2 can be solved for by using the Pythagorean Theorem a second time: The hypotenuse of the base, or the mystery length leg of the dashed triangle, can be solved by using the Pythagorean Theorem: D1 is the diagonal of the base and is limited to a 2D face. This will be the first use of the Pythagorean theorem. The next step of this problem is to solve for D1. We can already "map out" that D2 (the hypotenuse of the dashed triangle) can be solved by using the Pythagorean Theorem if we can obtain the length of the other leg (D1). Of this triangle that's outlined in pink dashed lines, the given information (the dimensions of the prism) provides a length for one of the legs (16). , where the diagonal of interest is D2, and D1 is the diagonal that cuts from corner to corner of the bottom face of the prism. This equation will be used twice to solve for the dashed line.įor the first step of this problem, it's helpful to imagine a triangle "slice" that's being taken inside the prism. In order to solve for the diagonal length, all that's required is the Pythagorean Theorem. This kind of a problem may seem to be a little more complicated than it really is. Let us solve some examples to understand the concept better.The length of the diagonal is from the bottom left hand corner closest to us to the top right hand corner that's farthest away from us. Total Surface Area ( TSA) = ( b × h) + ( s 1 + s 2 + s 3) × l, here, s 1, s 2, and s 3are the base edges, h = height, l = length The formula to calculate the TSA of a triangular prism is given below: The total surface area (TSA) of a triangular prism is the sum of the lateral surface area and twice the base area. Lateral Surface Area ( LSA ) = ( s 1 + s 2 + s 3) × l, here, s 1, s 2, and s 3 are the base edges, l = length Total Surface Area The formula to calculate the total and lateral surface area of a triangular prism is given below: The lateral surface area (LSA) of a triangular prism is the sum of the surface area of all its faces except the bases. It is expressed in square units such as m 2, cm 2, mm 2, and in 2. The surface area of a triangular prism is the entire space occupied by its outermost layer (or faces). Like all other polyhedrons, we can calculate the surface area and volume of a triangular prism. So, every lateral face is parallelogram-shaped. Oblique Triangular Prism – Its lateral faces are not perpendicular to its bases.Right Triangular Prism – It has all the lateral faces perpendicular to the bases. LU factorization performance in the beta isn’t too bad but it didn’t blow me away. As a result, ODE performs better on M1 compared to x86 architecture.” LU factorization performance A more aggressive out-of-order pipeline can significantly improve instruction level parallelism (ILP) for sequential programs. As an example, M1 includes a wider decoder, issue queues, register renaming, more ALUs, and a larger L1 cache. They told me “ODE is a sequential program, so its performance depends heavily on the performance of a single CPU core. I reached out to the development team and asked what was going on. Indeed, the ODE result for native Apple Silicon is faster than all of the other systems included in the R2022a bench results. ODE Performance is great in the Apple Silicon Beta of R2022aĪs you can see, Ordinary Differential Equation (ODE) solving performance is superb for the new beta. Let’s zoom in on a couple of these results. This is a great start but its definitely not true for all application benchmarks we’ve tried and we encourage you to give us feedback when you find something in the beta that doesn’t perform at least as well as R2022a under Rosetta. Let’s see how this compares to R2022a running under Rosetta 2 on the same machine:Įverything measured in bench shows better performance in the native beta than in the production version running on Rosetta. The first thing I did on launching the Native Apple Silicon Beta of MATLAB on an M1 Pro (with 10 CPU cores and 16 GPU cores) was to run bench twice using the command bench(2) Try it out and let us know what you find using this feedback form What did I find in the beta? The beta is available at to everyone who has a MATLAB license. That is, its a work in progress that shouldn’t be used in production environments and MathWorks are really interested in getting your feedback. The good news is that the answer is ‘Right now!’ The bad news is that its MATLAB only (no toolboxes or Simulink yet) and its still in beta. MATLAB beta on Native Apple Silicon available nowĮver since the M1 release, MATLAB users have been asking the question “When is a native Apple Silicon version going to be available?”. MathWorks made use of this and MATLAB has been supported on Apple Silicon Macs via Rosetta 2 since R2020b Update 3. This gives vendors time to manage the transition. Decades of person-years in fact! Fortunately, Apple understands this and, just as they did for the PowerPC to Intel transition in 2005, they created a compatibility layer called Rosetta 2 that allows software targeted at Intel Processors to run on the new architecture. It takes a lot of time to port applications as complex as MATLAB, Simulink, Simscape etc to a new CPU architecture. There was a small problem though: One does not simply release an Apple Silicon port of MATLAB! Naturally, everybody wanted to use all of their favorite applications on the new hardware from day one. When Apple released the M1 chip, the first version of their new ARM-based processors, in November 2020, it caused a great deal of excitement in the computing world. Update 8th December 2022: You may be interested in the newer Apple Silicon beta that’s discussed at Playing with the R2022b MATLAB Apple Silicon beta for M1/M2 Mac » The MATLAB Blog – MATLAB & Simulink () In the event of an update, the game will break and you won't be able to see other games. Click OK, the Steam Login screen shows up.A pop-up appears with a Critical Error message:.Note: This path is different might be different on your machine, so make sure you play around with the contents of your PlayOnMac directory. Using the terminal, type the following (without $): $ Library/PlayOnMac/wineprefix/Steam/drive_c/Program Files/Steam/steamapps/common/Age2HD If you try to load the game, you will get stuck on the Validating Subscriptions screen. In Steam, click "Play" for Age of Empires.Click the Local Files tab, and then click the "Browse local files" button to open the game files folder.Right click Age of Empires II HD in the mini version of Steam.After the game installs, go back to the original instructions of the installation for Starting Game:.Install the game on the mini version of Steam.Type wine steam.exe -no-browser +open steam://open/minigameslist I am trying to play Age of Empires 2 The Definitive Edition on macOS Mojave via Playonmac, but I get the errorm as written on the title.In the "General" tab, go down to the "Arguments".From here you can easily launch, uninstall or configure these applications. Select "Steam" and click "Run" in PlayOnMac This list will include all applications installed with PlayOnLinux or PlayOnMac, which is also a list of shortcuts.In the "Wine version" dropdown, select the latest one.Unlike other methods of running Windows software, Wine doesn't emulate Windows itself. On the left-hand side, select the latest one, and click the arrow button in the middle What Is PlayOnMac, and How Does It Work PlayOnMac is an application for macOS that allows you to play Windows games through the use of software called Wine.Next to "Wine version" click the button with a plus icon on it.Once that is finished installing, select "Steam" and click "Configure" in PlayOnMac.If it asks how much memory your graphics board has, select 1024.If you are using an M1 Mac, no payment is required to use the Insider Preview of Windows 10 on ARM or Windows 11 on ARM during this 14-day trial. There is a 14-day free, full-featured trial of Parallels Desktop 17. Copy and paste this into your browser's address bar, then press enter: playonmac:// Even better than a refund, you can test the game without any payment to either Parallels or Microsoft.Press the CTRL key and double click the PlayOnMac application (you only need to do this the first time).Open Finder, click "Applications" in the left sidebar, and look for the PlayOnMac item.Close the menu that opened, and you can delete the PlayOnMac.dmg file.Drag the PlayOnMac.app file onto the Applications folder in the menu that opens.Open the PlayOnMac.dmg file when it finishes downloading.Click this or run brew cask install playonmac.Sign in and purchase the game for $19.99.This configuration worked for macOS High Sierra, Version 10.13.6.Īccording to the original Gist, PlayOnMac does not work on macOS Catalina, and issues have been reported with the latest version of Steam. Historically, triple therapy has been prescribed with two separate inhalers, namely an ICS plus LABA inhaler and a LAMA inhaler. Routes to the instigation of triple therapy in patients with COPD.Ībbreviations: LABA, long-acting beta 2-agonist LAMA, long-acting muscarinic antagonist ICS, inhaled corticosteroid. 5 Mortality appears to be up to five times higher after the 10th severe exacerbation compared with that following the first hospitalization for COPD. 5, 7 – 9 Daily mortality, for instance, peaks at 40 per 10,000 of the population in the first week after admission for a severe exacerbation. 6 Moreover, exacerbations account for about 25% of the decline in lung function, increase the risk of mortality and hospital admissions, and reduce HRQoL in people with COPD. For example, the risk of myocardial infarction was 2.27-fold higher 1–5 days after a COPD exacerbation and the risk of stroke was 1.26-fold higher between 1 and 49 days later. 3 COPD is characterized by a progressive deterioration in lung function over many years, punctuated by periodic exacerbations, 5 which drive much of the morbidity and mortality associated with COPD. 4 Partly driven by demographic changes, COPD mortality is rising. Moreover, COPD is predominately a disease of older people. 3 However, other causes of mortality have shown a greater decline. 1 Age- and sex-specific mortality from COPD has declined in recent years. 2ĭespite a decrease in the number of people who smoke, COPD represented 5.3% of the total mortality in the UK in 2012. 1 The intangible costs arising from excess mortality and reduced health-related quality of life (HRQoL) in people with COPD far exceed the direct costs to health services and indirect costs associated with, for example, lost productivity. Studies using real-world evidence need to confirm these benefits.Īccording to the British Lung Foundation, ~1.2 million people have been diagnosed with COPD in the UK. HCPs should consider referral: 1) when there is limited response to treatment and persistent exacerbations 2) where there is diagnostic uncertainty or suspected comorbidity 3) whenever they feel “out of their depth.” Overall, the panel concurred that when used correctly, SITT has the potential to improve adherence, symptom control, and quality of life, and reduce exacerbations. Training, counseling, and education should be individualized. ICSs should be continued when the history suggests that asthma overlaps with COPD. In this situation, the blood eosinophil count could aid decision making. If patients exacerbate despite adhering to triple therapy, an individualized approach should be considered if the inhaled corticosteroid (ICS) confers benefit or causes side effects. During each review, HCPs should consider stepping treatment up or down. Appropriate non-pharmacological management is essential for all patients and should be considered before stepping up treatment. The panel suggested three criteria, any one of which identifies a high-risk patient where escalation to triple therapy from monotherapy or double combination treatment is appropriate: 1) at least two exacerbations treated with oral corticosteroids, antibiotics, or both in the previous year 2) at least one severe exacerbation that required hospital admission in the previous year 3) one exacerbation a year on a repeated basis for 2 consecutive years. The survey confirmed the need to clarify the place of SITT in COPD management. A survey of UK health care professionals (HCPs) identified issues around, and attitudes toward, SITT, which informed a multidisciplinary expert panel’s discussions. This paper offers practical, patient-focused advice to optimize placement of SITT in the management of COPD. While single-inhaler triple therapy (SITT) devices were not available when the Global Initiative for Chronic Obstructive Lung Disease strategy and National Institute for Health and Care Excellence guidelines were developed, two devices are now available in the UK. |
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