Assessment of clinical validity of KPG index for 3D classification of impacted maxillary canines by cone beam computed tomography in patients.

OBJECTIVES: The primary objective of this study was to assess the validity of the KPG index in predicting the difficulty of treatment involving impacted maxillary canines. The secondary objective was to assess the reliability and reproducibility of the index. MATERIALS AND METHODS: A retrospective study was conducted on 96 maxillary impacted canines (MIC) in 60 patients aged 13-35 years. Cone-beam computed tomography (CBCT) scans were used to predict the treatment difficulty of MIC using the KPG index. Patient case files were assessed for the actual difficulty encountered in treating MIC. Cohen's kappa correlation coefficient was used for intra-observer reliability and Kendell's W test was used for inter-observer reliability. Spearman's correlation coefficient test was used to assess the correlation between predicted and actual treatment. RESULTS: Easy and moderately difficult cases exhibited a moderate correlation between actual and predicted treatment outcomes, whereas difficult cases displayed a weak correlation. The perfect correlation was observed exclusively in extremely difficult cases. The intra-observer reliability for assessing CBCT scans using the KPG guide was found to be 0.88, and the inter-rater reliability was 0.94. CONCLUSION: The KPG index displayed 87%, 71%, 50% and 100% validity in easy, moderately difficult, difficult, and extremely difficult cases, respectively. This index showed good reliability and reproducibility. However, it is imperative to consider a multitude of other factors, including the patient's age, presence of associated root resorption in adjacent teeth, and duration of treatment, to make an informed decision between surgical exposure and extraction.

In-line ultra-thin attosecond delay line with direct absolute-zero delay reference and high stability.

We introduce an ultra-thin attosecond optical delay line based on controlled wavefront division of a femtosecond infrared pulse after transmission through a pair of micrometer-thin glass plates with negligible dispersion effects. The time delay between the two pulses is controlled by rotating one of the glass plates from absolute zero to several optical cycles, with 2.5 as to tens of attosecond resolution with 2 as stability, as determined by interferometric self-calibration. The performance of the delay line is validated by observing attosecond-resolved oscillations in the yield of high harmonics induced by time delayed infrared pulses, in agreement with a numerical simulation for a simple model atom. This approach can be extended in the future for performing XUV-IR attosecond pump-probe experiments.

Aging phenotype(s) in kidneys of diabetic mice are p66ShcA dependent.

The p66ShcA protein controls cellular responses to oxidative stress, senescence, and apoptosis. Here, we test the hypothesis that aging phenotype(s) commonly associated with the broad category of chronic kidney disease are accelerated in diabetic kidneys and linked to the p66ShcA locus. At the organ level, tissue stem cells antagonize senescent phenotypes by replacing old dysfunctional cells. Using established methods, we isolated a highly purified population of stem cell antigen-1-positive mesenchymal stem cells (Sca-1+ MSCs) from kidneys of wild-type (WT) and p66 knockout (p66 KO) mice. Cells were plated in culture medium containing normal glucose (NG) or high glucose (HG). Reactive oxygen species (ROS) metabolism was substantially increased in WT MSCs in HG medium in association with increased cell death by apoptosis and acquisition of the senescent phenotype. DNA microarray analysis detected striking differences in the expression profiles of WT and p66 KO-MSCs in HG medium. Unexpectedly, the analysis for p66 KO-MSCs revealed upregulation of Wnt genes implicated in self-renewal and differentiation. To test the in vivo consequences of constitutive p66 expression in diabetic kidneys, we crossed the Akita diabetic mouse with the p66KO mouse. Homozygous mutation at the p66 locus delays or prevents aging phenotype(s) in the kidney that may be precursors to diabetic nephropathy.

The processing and heterostructuring of silk with light.

Spider silk is a tough, elastic and lightweight biomaterial, although there is a lack of tools available for non-invasive processing of silk structures. Here we show that nonlinear multiphoton interactions of silk with few-cycle femtosecond pulses allow the processing and heterostructuring of the material in ambient air. Two qualitatively different responses, bulging by multiphoton absorption and plasma-assisted ablation, are observed for low- and high-peak intensities, respectively. Plasma ablation allows us to make localized nanocuts, microrods, nanotips and periodic patterns with minimal damage while preserving molecular structure. The bulging regime facilitates confined bending and microwelding of silk with materials such as metal, glass and Kevlar with strengths comparable to pristine silk. Moreover, analysis of Raman bands of microwelded joints reveals that the polypeptide backbone remains intact while perturbing its weak hydrogen bonds. Using this approach, we fabricate silk-based functional topological microstructures, such as Mobiüs strips, chiral helices and silk-based sensors.

Differences in carbon source utilisation by orchid mycorrhizal fungi from common and endangered species of Caladenia (Orchidaceae).

Terrestrial orchids depend on orchid mycorrhizal fungi (OMF) as symbionts for their survival, growth and nutrition. The ability of OMF from endangered orchid species to compete for available resources with OMF from common species may affect the distribution, abundance and therefore conservation status of their orchid hosts. Eight symbiotically effective OMF from endangered and more common Caladenia species were tested for their ability to utilise complex insoluble and simple soluble carbon sources produced during litter degradation by growth with different carbon sources in liquid medium to measure the degree of OMF variation with host conservation status or taxonomy. On simple carbon sources, fungal growth was assessed by biomass. On insoluble substrates, ergosterol content was assessed using ultra-performance liquid chromatography (UPLC). The OMF grew on all natural materials and complex carbon sources, but produced the greatest biomass on xylan and starch and the least on bark and chitin. On simple carbon sources, the greatest OMF biomass was measured on most hexoses and disaccharides and the least on galactose and arabinose. Only some OMF used sucrose, the most common sugar in green plants, with possible implications for symbiosis. OMF from common orchids produced more ergosterol and biomass than those from endangered orchids in the Dilatata and Reticulata groups but not in the Patersonii and Finger orchids. This suggests that differences in carbon source utilisation may contribute to differences in the distribution of some orchids, if these differences are retained on site.

Door to disposition times for obstetric triage visits: Is there a July phenomenon?

The July phenomenon refers to a change in patient outcomes within teaching hospitals with the arrival of new and inexperienced house staff at the start of the academic year (July to June). In our obstetric triage unit we retrospectively evaluated the door to disposition time (DTDT) for 1817 patients who presented across July, December and May of academic years 2009-2010 and 2010-2011. DTDT was examined for three visit levels: non-urgent, urgent and emergent. No significant differences in disposition time were found for emergent visits. For urgent visits the median DTDT significantly decreased from 171 min in July to 155 min in December and 135 min in May (p < 0.001). Similarly for non-urgent visits, the median DTDT was greater during July than May (179 min vs. 133 min; p < 0.05). Electronic medical records (EMRs) were implemented in November 2010. Following the introduction of EMR shorter DTDT was seen in December 2010 versus December 2009 (median, 171 min vs. 150 min; p < 0.05), respectively. Our findings suggest a 'July Phenomenon' of greater disposition intervals for urgent and non-urgent obstetric triage visits across the academic year. Additionally the use of EMRs may facilitate patient flow through the OB triage unit.

Dynamic changes in PDMS surface morphology in femtosecond laser treatment.

We have investigated the effect of the dynamics of crater size on the poly(dimethylsiloxane) (PDMS) surface morphology in fs-laser micro-processing. PDMS surface was processed with varying both inter-pulse interval and inter-spot distance between successive laser pulses. With keeping the interval of 5 ms crater shape is round even if the spot is overlapped in space. But decreasing the interval to 0.02 ms the shape of the crater is no longer round. Decreasing the inter-distance between the craters results in roughened surface morphology even at time intervals of 5 ms. Temporal dependence of single-shot fs-laser induced crater size was measured as a function of time delay. Within 0.1 ms after pulse irradiation with a fluence of 4.8 J/cm2 on PDMS surface the crater size has reached to its maximum values and then decreased with a time constant of about 0.3 ms. The surface morphology after fs-laser pulse irradiation is strongly dependent on not only inter-spot distance between successive laser pulse but also their inter-pulse intervals. By proposing a theoretical model on their dynamic features, we will try to explain the current observation in quantitatively.

IRF5rs2004640 single nucleotide polymorphism is associated with susceptibility to rheumatoid arthritis in South Indian Tamils.

Polymorphism of interferon regulatory factor 5 (IRF5), a latent transcription factor gene has been associated with various auto-immune diseases. Our aim was to study the IRF5rs2004640 gene polymorphism and its association with disease susceptibility, disease phenotype and treatment response in South Indian Tamil patients with rheumatoid arthritis (RA).The study was conducted on 217 RA patients fulfilling the American College of Rheumatology (ACR) 2010 criteria and 482 healthy controls (HCs) without family history of autoimmune disease. The IRF5rs2004640 genotyping was performed using a TaqMan 5' allelic discrimination assay. We found that the IRF5rs2004640T allele [P < 0.0001, odds ratio (OR) 3.25, 95% confidence interval (CI) 2.55-4.12] and TT genotype (P < 0.0001, OR 4.60, 95% CI 3.23-6.57) were significantly more frequent in RA patients as compared with HCs. No association was found between IRF5rs2004640 polymorphism, clinical manifestations, autoantibody profile and treatment response. IRF5rs2004640 T (mutant) allele may be a susceptibility factor conferring risk for RA in South Indian Tamils, whereas G allele (wild type) may be protective.

Prevalence and clinical profiles of 'autoantibody-negative' systemic sclerosis subjects.

OBJECTIVES: To determine the prevalence of autoantibody negative systemic sclerosis (SSc) and to identify the clinical correlates thereof. METHODS: Clinical data and sera from 874 SSc subjects were collected and autoantibodies were tested in a central laboratory using 1) indirect immunofluorescence (IIF), 2) commercially available ELISA, addressable laser bead immunoassay (ALBIA), and line immunoassay (LIA), and 3) a sensitive immunoprecipitation (IP) assay. RESULTS: Fifteen (15; 1.7%) subjects were autoantibody negative by IIF, ELISA, ALBIA, LIA and IP, and 16 (1.8%) were antinuclear antibody (ANA) positive by IIF but otherwise negative by ELISA, ALBIA, LIA and IP. Thirty-seven (37; 4.2%) were ANA positive by IIF, autoantibody negative by commercially available immunoassays, but had autoantibodies identified by IP (including Th/To in 20). Autoantibody-negative subjects had generally less severe disease than positive subjects. CONCLUSIONS: Autoantibody-negative SSc is rare (<2%) and appears to be associated with a favourable prognosis.

Femtosecond laser-assisted selective reduction of neovascularization in rat cornea.

Nonlinear multiphoton absorption induced by focusing near infrared (NIR) femtosecond (fs) laser pulses into a transparent cornea allows surgery on neovascular structures with minimal collateral damage. In this report, we introduce an fs laser-based microsurgery for selective treatment of rat corneal neovascularizations (in vivo). Contiguous tissue effects are achieved by scanning a focused laser pulse below the corneal surface with a fluence range of 2.2-8.6 J/cm(2). The minimal visible laser lesion (MVL) threshold determined over the corneal neovascular structures was found to be 4.3 J/cm(2). Histological and optical coherence tomography examinations of the anterior segment after laser irradiations show localized degeneration of neovascular structures without any unexpected change in adjacent tissues. Furthermore, an approximately 30 % reduction in corneal neovascularizations was observed after 5 days of fs laser exposure. The femtosecond laser is thus a promising tool for minimally invasive intrastromal surgery with the aid of a significantly smaller and more deterministic photodisruptive energy threshold for the interaction between the fs laser pulse and corneal neovascular structures.

Laser-disintegrated copper-activated salicylic acid (Cu-SA) nanoparticles suppressed the seed-borne pathogens of rice with enhanced seed invigoration parameters.

Leading phytopathological research is focused on managing seed-borne pathogens of rice through the utilization of engineered nanomaterials. Herein, blue laser-induced topo-morphologically nano-advanced copper salicylates (Cu-SA) (Cu/SA in 1:1 and 1:2 ratio) were prepared and evaluated for their augmented antifungal potential along seed invigoration effects in contrast to their prepared sonicated formulations. Laser disintegration on the Cu-SA (Cu/SA in 1:1 and 1:2 ratio) was achieved with high degree of success and precision using blue laser, which yielded uniformly distributed spherical nanoparticles with a narrow size distribution and better crystallinity than aqua-dispersed sonicated formulations. In vitro antifungal evaluation against seed-borne fungi of rice viz. Fusarium verticillioides and Fusarium fujikuroi revealed multiple times the augmented potential of laser-disintegrated nanoformulations (l-CuSA) than sonicated (s-CuSA) and bulk samples. Laser-induced nano-sodium bis(2-oxobenzoato)cuprate (II) (l-CuSA2) with Cu/SA in 1:2 ratio was the best to inhibit the in vitro fungal growth. Ultra-micrographs and fungal double-staining assay further rationalized the membrane disruption as the mode of action for the fungitoxicity. Nanopriming of fungal infested rice seeds with l-CuSA2 at 2500 µg/mL for 8 h showed the maximum reduction of seed rot (80.43%) and seedling blight (63.15%) with respect to control (untreated). The seed-invigorating factors of l-CuSA2 nanoprimed seeds were enhanced to maximum extent and showed the highest per cent germination (35.29%), shoot length (11.42%), root length (21.14%), dry weight (75.43%) and vigour index (81.04%) over the control. Inclusively, the seed nanopriming with l-CuSA2 proved as agro-compatible hypo-toxic semi natural nanoplatform for sustainable agriculture.

Biochar influences nitrogen and phosphorus dynamics in two texturally different soils.

Nitrogen (N) and phosphorus (P) are vital for crop growth. However, most agricultural systems have limited inherent ability to supply N and P to crops. Biochars (BCs) are strongly advocated in agrosystems and are known to improve the availability of N and P in crops through different chemical transformations. Herein, a soil-biochar incubation experiment was carried out to investigate the transformations of N and P in two different textured soils, namely clay loam and loamy sand, on mixing with rice straw biochar (RSB) and acacia wood biochar (ACB) at each level (0, 0.5, and 1.0% w/w). Ammonium N (NH4-N) decreased continuously with the increasing incubation period. The ammonium N content disappeared rapidly in both the soils incubated with biochars compared to the unamended soil. RSB increased the nitrate N (NO3-N) content significantly compared to ACB for the entire study period in both texturally divergent soils. The nitrate N content increased with the enhanced biochar addition rate in clay loam soil until 15 days after incubation; however, it was reduced for the biochar addition rate of 1% compared to 0.5% at 30 and 60 days after incubation in loamy sand soil. With ACB, the net increase in nitrate N content with the biochar addition rate of 1% remained higher than the 0.5% rate for 60 days in clay loam and 30 days in loamy sand soil. The phosphorus content remained consistently higher in both the soils amended with two types of biochars till the completion of the experiment.

Beyond pregnancy--the neglected burden of mortality in young women of reproductive age in Bangladesh: a prospective cohort study.

OBJECTIVE: To describe proportionate mortality and causes of death unrelated to pregnancy. DESIGN: Prospective cohort study. SETTING: Rural northwest Bangladesh. POPULATION: A cohort of 133,617 married women of reproductive age. METHODS: Verbal autopsies were conducted for women who died whilst under surveillance in the cohort trial. Physician-assigned causes of death based on verbal autopsies were used to categorise deaths. MAIN OUTCOME MEASURES: The proportion of deaths due to non-communicable diseases, infectious diseases, injury or pregnancy. RESULTS: Of the 1107 deaths occurring among women between 2001 and 2007, 48% were attributed to non-communicable diseases, 22% to pregnancy, 17% to infections, 9% to injury and 4% to other causes. CONCLUSIONS: Although focus on pregnancy-related mortality remains important, more attention is warranted on non-communicable diseases among women of reproductive age.

Nanodiamonds enable femtosecond-processed ultrathin glass as a hybrid quantum sensor.

The quantum properties of fluorescent nanodiamonds offer great promise for fabricating quantum-enabled devices for physical applications. However, the nanodiamonds need to be suitably combined with a substrate to exploit their properties. Here, we show that ultrathin and flexible glass (thickness 30 microns) can be functionalized by nanodiamonds and nano-shaped using intense femtosecond pulses to design cantilever-based nanomechanical hybrid quantum sensors. Thus fabricated ultrathin glass cantilevers show stable optical, electronic, and magnetic properties of nitrogen-vacancy centers, including well-defined fluorescence with zero-phonon lines and optically detected magnetic resonance (ODMR) near 2.87 GHz. We demonstrate several sensing applications of the fluorescent ultrathin glass cantilever by measuring acoustic pulses, external magnetic field using Zeeman splitting of the NV centers, or CW laser-induced heating by measuring thermal shifting of ODMR lines. This work demonstrates the suitability of the femtosecond-processed fluorescent ultrathin glass as a new versatile substrate for multifunctional quantum devices.

Dengue fever evolving into systemic lupus erythematosus and lupus nephritis: a case report.

Dengue viremia may be the trigger for immune complex formation in patients who are predisposed to developing autoimmune disease. We report a rare case of dengue virus infection evolving into systemic lupus erythematosus (SLE) and lupus nephritis. To the best of our knowledge this is the first case of dengue fever evolving into lupus nephritis. A 22 year old female presented with having had high grade fever, skin rash, breathlessness, retro-orbital pain, abdominal pain, arthralgias and myalgias for 10 days. She tested positive for dengue immunoglobulin M (IgM). She was given supportive treatment and was subsequently discharged. Four weeks later she developed recurrent fever, arthralgia, rash and anasarca. She was suspected as having SLE with active lupus nephritis. Antinuclear antibody (ANA), and anti double stranded deoxyribonucleic acid (anti dsDNA) titers were positive and complements were low. Renal biopsy showed diffuse proliferative glomerulonephritis grade IV. She was treated with steroids and immunosuppressants to which she responded. Dengue viremia incites antibody production, which if excessive causes deposition of viral antigen-antibody immune complexes. This could possibly lead to renal tubular damage and glomerulonephritis in susceptible individuals. Dengue fever leading to development of glomerulonephritis is rarely seen. Our patient developed dengue fever and after a month presented with manifestations of SLE and lupus nephritis. Both dengue fever and SLE have common manifestations of fever, arthralgia, rash, leucopenia with thrombocytopenia and serositis. Bacterial and viral infections may act as a 'trigger' for starting or relapsing lupus activity in genetically predetermined individuals. In our case it may be possible that dengue virus could have triggered a dysfunctional immune response, resulting in the developing of autoimmunity and SLE with lupus nephritis.

The non-human primate model of tuberculosis.

Non-human primates (NHPs) are used to model human disease owing to their remarkably similar genomes, physiology, and immune systems. Recently, there has been an increased interest in modeling tuberculosis (TB) in NHPs. Macaques are susceptible to infection with different strains of Mycobacterium tuberculosis (Mtb), producing the full spectrum of disease conditions, including latent infection, chronic progressive infection, and acute TB, depending on the route and dose of infection. Clearly, NHPs are an excellent model of human TB. While the initial aim of the NHP model was to allow preclinical testing of candidate vaccines and drugs, it is now also being used to study pathogenesis and immune correlates of protection. Recent advances in this field are discussed in this review. Key questions such as the effect of hypoxia on the biology of Mtb and the basis of reactivation of latent TB can now be investigated through the use of this model.

Olecranon Osteotomy by a Gigli Saw versus Chevron's Osteotomy for Exposure of Intra-articular Distal Humerus: A Comparative Study.

Introduction: Olecranon osteotomy is employed for the fixation of intraarticular distal humeral fractures. We conducted a prospective, randomised study comparing Chevron's osteotomy with olecranon osteotomy by a Gigli saw for exposure of the intraarticular distal humerus in terms of functional outcome and intra-operative ease of the surgery. Materials and methods: Thirty patients with skeletally mature AO/OTA type 13- B and 13-C distal humerus fractures were randomly allocated to Chevron's or Gigli saw groups. Each group consisted of a total of 15 patients. Both the groups were assessed on post-operative parameters including arm, shoulder or hand pain, ability to perform certain routine activities, tingling sensations and pain while sleeping. Results: In the Gigli saw group, 12 patients had no gross limitation of activity and 13 were able to perform moderate activities with ease. Similar results were observed in the Chevron's group. The mean difference between the two groups in Oxford Score was 0.60, within the 95% confidence interval and in line with QuickDASH-11 Score. Conclusion: Chevron's technique offers stability and better healing, providing a larger surface area for bone union. However, it is challenging and time-consuming. Also, literature suggests that the Gigli saw has multiple benefits, saves time and effort, and heals by switching blood supply from centrifugal to centripetal post-operatively. Our study suggests that both Chevron's technique and the use of the Gigli saw are effective in distal humeral intra-articular fractures as assessed by multiple parameters. Hence both techniques can be equally used depending on the surgeon's preference.

Attosecond stable dispersion-free delay line for easy ultrafast metrology.

We demonstrate a dispersion-free wavefront splitting attosecond resolved interferometric delay line for easy ultrafast metrology of broadband femtosecond pulses. Using a pair of knife-edge prisms, we symmetrically split and later recombine the two wavefronts with a few tens of attosecond resolution and stability and employ a single-pixel analysis of interference fringes with good contrast using a phone camera without any iris or nonlinear detector. Our all-reflective delay line is theoretically analyzed and experimentally validated by measuring 1st and 2nd order autocorrelations and the SHG-FROG trace of a NIR femtosecond pulse. Our setup is compact, offers attosecond stability with flexibility for independent beam-shaping of the two arms. Furthermore, we suggest that our compact and in-line setup can be employed for attosecond resolved pump-probe experiments of matter with few-cycle pulses.

Polymorphisms of the gamma crystallin A and B genes among Indian patients with pediatric cataract.

BACKGROUND: Previous familial studies have reported co-segregation of mutation in gamma crystallin A and B CRYGA and CRYGB genes with childhood cataract. AIM: We investigated association of nucleotide variations in these genes in subjects with and without pediatric cataract from India. SETTINGS AND DESIGN: The study included 195 pediatric subjects including healthy children with no ocular defects and pediatric cataract cases. MATERIALS AND METHODS: Subjects were genotyped by PCR-RFLP method for exonic and intronic genetic variations in CRYGA and CRYGB. STATISTICAL ANALYSIS: The association of these polymorphisms with cataract was estimated by two way contingency tables and the risk allele was also analyzed for their functional impact using in silico tools. Results : No significant difference was observed between cases and control subjects for the frequencies of SNPs G198A (Intron A), T196C (Exon 3) of CRYGA and G449T (Exon 2) of CRYGB gene. -47C allele of rs2289917 in CRYGB showed the strongest association with cataract (Odd Ratio-OR=3.34, 95% Confidence Interval-CI 95% =1.82-6.12, P=0.00007). In silico analyses revealed that this polymorphism lies in a phylogenetically conserved region and impacts binding of a transcription factor, viz. progesterone receptor (PR) to CRYGB promoter. CONCLUSION: rs2289917 risk allele showed a strong association with increased vulnerability for pediatric cataract. The findings suggest that this association may be a secondary phenomenon related to genetic variation playing critical role in lens development during perinatal and/or pediatric growth. Present exploratory study provides a basis for further defining the role of PR as a regulator of CRYG locus in lens formation/transparency.

Tiotropium as a first maintenance drug in COPD: secondary analysis of the UPLIFT trial.

The aim of the present study was investigate the long-term effect of tiotropium as first maintenance respiratory medication in chronic obstructive pulmonary disease (COPD). A 4-yr, randomised, multicentre, double-blind, parallel-group, placebo-controlled trial (Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT) was conducted. Analysis focused on the effect of tiotropium versus matching placebo in the 810 (13.5%) COPD patients not on other maintenance treatment (long-acting beta-agonists, inhaled corticosteroids, theophyllines or anticholinergics) at randomisation. Spirometry, health-related quality of life (St George's Respiratory Questionnaire (SGRQ) score), exacerbations of COPD and mortality were also analysed. 403 patients (mean+/-sd age 63+/-8 yrs, post-bronchodilator forced expiratory volume in 1 s (FEV(1)) 53+/-12% predicted) received tiotropium and 407 (64+/-8 yrs of age, post-bronchodilator FEV(1) 51+/-12% pred) received placebo. Post-bronchodilator FEV(1) decline was 42+/-4 mL.yr(-1) in the tiotropium group and 53+/-4 mL.yr(-1) in the placebo group (p = 0.026). At 48 months, the morning pre-dose FEV(1) was 134 mL higher in the tiotropium group compared to the placebo group (p<0.001). SGRQ total score declined more slowly in the tiotropium group (difference of 1.05+/-0.34 units.yr(-1); p = 0.002). This was particularly significant for the impact (difference of 1.08+/-0.37 units.yr(-1); p = 0.004) and activity (1.44+/-0.40 units.yr(-1); p<0.001) domains, but not for symptoms (0.26+/-0.50 units.yr(-1); p = 0.6). At 48 months, the difference in total score was 4.6 units (p<0.001) with tiotropium compared to placebo. In patients with COPD who are not on maintenance therapy, tiotropium is associated with significant benefits in disease progression.