A prospective randomized trial comparing somatostatin and sclerotherapy in the treatment of acute variceal bleeding

Somatostatin and endoscopic sclerotherapy are widely used in the treatment of acute variceal bleeding. Although objective evidence does exist about the advantages of either treatment, data comparing both procedures are scarce. In order to compare the effectiveness and safety of somatostatin and sclerotherapy in the treatment of acute variceal bleeding, 70 consecutive cirrhotic patients suffering from esophageal variceal hemorrhage and meeting the inclusion criteria were randomly assigned to treatment with somatostatin (35 patients) or sclerotherapy (35 patients). No differences in age, sex, alcohol intake, etiology of cirrhosis and severity of liver failure were found between groups. Failure of treatment (defined as persistence of bleeding despite therapy or subsequent rebleeding within the 48-hr trial period) occurred in seven patients (20%) in the somatostatin group and in six (17.1%) in the sclerotherapy group (NS). Early rebleeding occurred in seven of 28 patients (25%) in the somatostatin group and in five of 29 (17.2%) in the sclerotherapy group (NS). Mortality within the first 6 wk was no different between both groups: 10 (28.5%) and eight (22.8%) in the somatostatin and sclerotherapy groups, respectively. Sclerotherapy, but not somatostatin, was associated with major complications in five cases (14.2%) (p = 0.026), two of which resulted in patient's death. These results suggest that somatostatin is safer, and as effective as sclerotherapy, in controlling acute variceal bleeding until an elective treatment can be established.     

Sequential changes of esophageal motility after endoscopic injection sclerotherapy or variceal ligation for esophageal variceal bleeding: a scintigraphic study

OBJECTIVE: Endoscopic injection sclerotherapy and variceal ligation are two popular endoscopic methods used to treat esophageal variceal hemorrhage. These two methods have not been compared with regard to esophageal dysfunction after treatment. This is a prospective investigation of esophageal dysmotility after endoscopic injection sclerotherapy and variceal ligation. METHODS: Sequential changes of esophageal motility after endoscopic injection sclerotherapy (n = 25) and variceal ligation (n = 25) were investigated in 50 cirrhotic patients with recent variceal bleeding. Another 22 cirrhotics without esophageal varices were included as controls. Radionuclide esophageal transit tests were performed before initial endoscopic treatment, and 1 and 3 months after variceal eradication. RESULTS: The baseline esophageal transit time was longer in both the sclerotherapy (n = 25, 7.8 +/- 1.4 s) and ligation groups (n = 25, 8.2 +/- 1.8 s) than in controls (n = 22, 6.7 +/- 0.7 s, p < 0.005). The transit time was longer in patients with large varices than in those with small varices (8.3 +/- 1.7 vs. 7.2 +/- 0.7 s, p < 0.05). In the sclerotherapy group, the transit time was prolonged 1 month after variceal eradication, compared with its pretreatment state (n = 20, 7.6 +/- 1.5 vs. 10.0 +/- 2.2 s, p < 0.0001) but was shortened at 3 months compared with 1 month after variceal eradication (n = 12, 10.7 +/- 1.5 vs. 8.6 +/- 2.2 s, p < 0.05). Multiple regression analysis showed that the number of treatment sessions required to eradicate varices was the only significant factor associated with prolonged transit time (p < 0.05). In the ligation group, the transit time changed little at 1 month or 3 months after variceal eradication. CONCLUSIONS: Impairment of esophageal motility can be significant with endoscopic injection sclerotherapy but is reversible. However, endoscopic variceal ligation exerts no significant impact on esophageal motility.     

Nadolol plus isosorbide mononitrate compared with sclerotherapy for the prevention of variceal rebleeding

BACKGROUND: Patients who have bleeding from esophageal varices are at high risk for rebleeding and death. We compared the efficacy and safety of endoscopic sclerotherapy with the efficacy and safety of nadolol plus isosorbide mononitrate for the prevention of variceal rebleeding. METHODS: Eighty-six hospitalized patients with cirrhosis and bleeding from esophageal varices diagnosed by endoscopy were randomly assigned to treatment with repeated sclerotherapy (43 patients) or nadolol plus isosorbide-5-mononitrate (43 patients). The primary outcomes were rebleeding, death, and complications. The hepatic venous pressure gradient was measured at base line and after three months. RESULTS: Base-line data were similar in the two groups, and the median follow-up was 18 months in both. Eleven patients in the medication group and 23 in the sclerotherapy group had rebleeding. The actuarial probability of remaining free of rebleeding was higher in the medication group for all episodes related to portal hypertension (P = 0.001) and variceal rebleeding (P = 0.002). Four patients in the medication group and nine in the sclerotherapy group died (P = 0.07 for the difference in the actuarial probability of survival). Seven patients in the medication group and 16 in the sclerotherapy group had treatment-related complications (P = 0.03). Thirty-one patients in the medication group underwent two hemodynamic studies; 1 of the 13 patients with more than a 20 percent decrease in the hepatic venous pressure gradient had rebleeding, as compared with 8 of the 18 with smaller decreases in the pressure gradient (P = 0.04) for the actuarial probability of rebleeding at two years). CONCLUSIONS: As compared with sclerotherapy, nadolol plus isosorbide mononitrate significantly decreased the risk of rebleeding from esophageal varices.     

Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomized study

BACKGROUND/AIMS: Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage. METHODS: Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment. RESULTS: The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively). CONCLUSIONS: Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.     

Sclerotherapy versus sclerotherapy and propranolol in the prevention of rebleeding from oesophageal varices: a randomised study

BACKGROUND: This trial was carried out to assess the value of propranolol in the prevention of recurrent variceal bleeding when combined with longterm endoscopic sclerotherapy. PATIENTS AND METHODS: Two hundred patients (161 male, 39 female, age range 20-68 years) with portal hypertension resulting mainly from schistosomal periportal fibrosis or posthepatitic cirrhosis presenting with their first episode of haematemesis or melena, or both were included. This was confirmed endoscopically to result from ruptured oesophageal varices. After initial control of bleeding, patients were randomised into two groups: group 1 treated with endoscopic sclerotherapy alone and group 2 treated with sclerotherapy plus propranolol. They were followed up for two years. RESULTS: Group (2) had a lower rebleeding rate (14.3% v 38.6% in group 1), lower variceal recurrence after obliteration (17% v 34% in group 1), longer period between variceal obliteration and recurrence (36 weeks v 21 weeks in group 1); but no change in mortality (12% in both groups). CONCLUSIONS: Patients treated with sclerotherapy should be given propranolol for longterm management.     

To do or not to do: Desirability and consistency mediate judgments of regret.

In 4 studies, the authors demonstrated that when errors associated with action were inconsistent with decision makers' orientation, they were undesirable and produced more regret than did errors associated with inaction. Conversely, when errors associated with action were consistent with decision makers' orientation, they were desirable and produced less regret than did errors associated with inaction. Desirability and consistency mediated this relationship, independent of mutability. These results were obtained when judgments and decisions to act or not act were made in close temporal proximity to one another as well as when participants reflected on their past decisions. The authors provide an analysis of when counterfactuals would and would not be expected to mediate judgments of normality and regret. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Preemption or prevention?: lessons from efforts to control firearms, alcohol, and tobacco

The judicial doctrine of preemption allows federal or state governments to restrict the ability of state or local governments, respectively, to regulate in a given area. Industries whose products create substantial public health risks have begun to promote preemptive legislation which prevents the lower levels of government from adopting strong public health protections. This article discusses the implications of preemptive legislation concerning three of the most harmful products available in America: tobacco, firearms and alcohol. These examples illustrate the potential danger that preemptive legislation poses to efforts to prevent illness, injury and death caused by these products.     

Failure of the nonselective beta-blocker propranolol to affect lipoprotein lipase gene expression in the rat

Treatment with beta-blockers has been reported to be associated with the development of hypertriglyceridemia. The etiology, even the existence, of this phenomenon is controversial. The purpose of our study was to examine whether the nonselective beta-blocker propranolol causes hypertriglyceridemia in the rat and whether its action is mediated by the modulation of lipoprotein lipase (LPL) messenger RNA (mRNA) accumulation or activity. LPL activity was assayed in fresh tissue by incubation with tritiated triglycerides. LPL mRNA was quantified in total RNA by slot-blot analysis using a mouse LPL complementary DNA probe. We have conducted three series of experiments in unanaesthetized rats in order to study the effects of different single doses of propranolol (1.5 to 6 mg i.p.) and different durations of treatment (15 min to 4 wk). We measured triglyceride and cholesterol levels in plasma as well as the LPL activity and mRNA levels in the heart and adipose tissue before and after propranolol administration. In these experiments we did not find any significant decrease in either the activity or the amount of mRNA of lipoprotein lipase nor was there any change in plasma lipids following treatment. Our results lead us to the conclusion that the nonselective beta-blocker propranolol affects neither the activity nor the mRNA level of LPL in the rat.     

What do comparative studies of inbred mice add to current investigations on the neural basis of spatial behaviors?

In the present article a number of comparative lesion studies in two inbred strains of mice (C57BL/6 and DBA/2) with different levels of radial maze performance are reviewed. The effects of lesions in several brain areas on maze learning were investigated, thus revealing strain differences in the neural circuitry subserving spatial cognition. Results showed that the hippocampus and parietal cortex appear to be involved in the control of radial maze learning in both C57 and DBA mice, although in a strain-dependent fashion. Lesions in other structures such as the medial frontal cortex and the amygdala only affected spatial learning in the C57 strain. Lastly, the results showed some improvement in radial maze performance in DBA mice with nucleus accumbens lesions. The data highlight the variability in the neural mechanisms subserving well-differentiated levels of spatial performance. The contribution of inbred mice to our general understanding of the neural basis of spatial cognition is discussed.     

Drug-abuse prevention efforts for young children: a review and critique of existing programs

Children under age five are increasingly the target of formal interventions aimed at deterring subsequent drug abuse. These prevention efforts are characterized, however, by a lack of empirical research on the variables involved in inoculating very young children against later drug use, and the lack of assessments research demonstrating their effectiveness. Curriculum-based antidrug programs for preschool children are reviewed, and developmental and early intervention research is used as the basis of recommendations for strengthening such efforts.     

What are the eating cognitions of children whose chronic diseases do and do not require attention to diet?

One of the current knowledge gaps in the evaluation of risk for human exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) is the relationship between gene expression induced by TCDDmore complex biological responses such as altered growth, differentiation, and neoplasia. This study investigates the dose-dependent expression of CYP1A1, CYP1A2,CYP1B1 in the livers of female Sprague-Dawley rats chronically exposed to TCDD. Animals were treated biweekly for 30 weeks with daily averaged doses of 0 to 125 ng TCDD/kg/day. Immunoblot analysis showed that protein levels for CYP1B1, CYP1A1, CYP1A2 exhibited a dose-dependent induction by TCDD. However, CYP1A1 and CYP1A2 protein levels were approximately 100-fold higher than CYP1B1, which could not be detected by either immunoblot analysis or immunohistochemistry in the livers of rats treated with TCDD for 30 weeks at a dose-equivalent less than 35.7 ng/kg/day. In control animals, CYP1A1CYP1A2 RNA levels, measured by quantitative RT-PCR, were 1100-15,000-fold higher than that of CYP1B1, respectively. TCDD induced CYP1B1 RNA levels at all doses, although absolute TCDD-induced levels of CYP1A1CYP1A2 at the highest dose (125 ng/kg/day) were more than 40-fold higher than that of CYP1B1. While the liver concentration of TCDD required for half-maximal induction of CYP1A1, CYP1A2,CYP1B1 RNA levels was similar, the shaping parameter (Hill coefficient) of the dose-response curve for CYP1B1 was significantly higher than that for CYP1A1 or CYP1A2. The low level of TCDD-induced CYP1B1 expression in the liver relative to that of the CYP1A1CYP1A2 suggest that, if CYP1B1 is involved in TCDD-induced hepatocarcinogenesis, its endogenous function is likely to be uniquenot overlapping with that of CYP1A1 or CYP1A2.     

Statistical testing and null distributions: What to do when samples are not random.

Selected literature related to statistical testing is reviewed to compare the theoretical models underlying parametric and nonparametric inference. Specifically, we show that these models evaluate different hypotheses, are based on different concepts of probability and resultant null distributions, and support different substantive conclusions. We suggest that cognitive scientists should be aware of both models, thus providing them with a better appreciation of the implications and consequences of their choices among potential methods of analysis. This is especially true when it is recognized that most cognitive science research employs design features that do not justify parametric procedures, but that do support nonparametric methods of analysis, particularly those based on the method of permutation/randomization. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Structures and policy of nosocomial infection prevention: France is speeding up the process

For the past 10 years France has tried to set up a programme to prevent and survey nosocomial infections and antibiotic resistance. A series of recommendations have been made available for hospitals. Hygiene, nosocomial infections, and resistance to antibiotics are recognized by medical doctors, nurses and administrative people as pertinent and logical quality indicators. Those indicators will probably be proposed by the French agency for accreditation and evaluation. We still need to define which events are preventable, which should be declared to the official agencies, and how to integrate infection control in a broader programme coordinating different systems of surveillance (drug, blood, ...) and risk management. We have also to make those informations available to the public in a more transparent mind.     

Transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding in portal hypertension: comparison of emergency and elective interventions

Nonsurgical reduction of portal hypertension by transjugular intrahepatic portosystemic shunt (TIPS) is widely used for prevention of variceal rebleeding (elective TIPS). Information is limited about the value of emergency TIPS for acute variceal bleeding unresponsive to endoscopic and drug therapy. The aim of the present study was therefore to determine whether the effects and complications differ between emergency and elective TIPS in patients with cirrhosis of the liver. TIPS was performed in 11 patients with acute variceal bleeding unresponsive to endoscopic treatment and 22 patients in stable condition after an episode of variceal bleeding. Clinical examination, blood sampling, Doppler sonography of TIPS flow, and upper gastrointestinal endoscopy were performed at days 1, 7, and 30 and at three-month intervals after TIPS. Mean follow-up was 549 (1-987) days. Bleeding was controlled by emergency TIPS in 10/11 patients. Probability of survival was not different after emergency and elective TIPS (0.73 vs 0.84 at one year). Early rebleeding (< or =2 weeks) occurred more often after emergency TIPS (3/11 vs 0/22 patients; P = 0.03), but there was no significant difference in late rebleeding. Occlusion of TIPS was more frequent after emergency TIPS. Occurrence of TIPS stenoses was identical in both groups (4/11 vs 8/22). De novo or deterioration of preexisting hepatic encephalopathy was similar (18% vs 24%; NS). It is concluded that TIPS is effective for control of acute variceal bleeding unresponsive to endoscopic and drug treatment. Early rebleeding and stent occlusion occurred more often after emergency TIPS. Late rebleeding, complications, and long-term survival did not differ from elective TIPS.