19 research outputs found
Emergency Portacaval Shunt Versus Rescue Portacaval Shunt in a Randomized Controlled Trial of Emergency Treatment of Acutely Bleeding Esophageal Varices in Cirrhosis—Part 3
Emergency treatment of bleeding esophageal varices in cirrhosis is of singular importance because of the high mortality rate. Emergency portacaval shunt is rarely used today because of the belief, unsubstantiated by long-term randomized trials, that it causes frequent portal-systemic encephalopathy and liver failure. Consequently, portacaval shunt has been relegated solely to salvage therapy when endoscopic and pharmacologic therapies have failed. Question: Is the regimen of endoscopic sclerotherapy with rescue portacaval shunt for failure to control bleeding varices superior to emergency portacaval shunt? A unique opportunity to answer this question was provided by a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt conducted from 1988 to 2005.
Unselected consecutive cirrhotic patients with acute bleeding esophageal varices were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup was completed and treatment was initiated within 8 h. Failure of endoscopic sclerotherapy was defined by strict criteria and treated by rescue portacaval shunt (n = 50) whenever possible. Ninety-six percent of patients had more than 10 years of follow-up or until death.
Comparison of emergency portacaval shunt and endoscopic sclerotherapy followed by rescue portacaval shunt showed the following differences in measurements of outcomes: (1) survival after 5 years (72% versus 22%), 10 years (46% versus 16%), and 15 years (46% versus 0%); (2) median post-shunt survival (6.18 versus 1.99 years); (3) mean requirements of packed red blood cell units (17.85 versus 27.80); (4) incidence of recurrent portal-systemic encephalopathy (15% versus 43%); (5) 5-year change in Child’s class showing improvement (59% versus 19%) or worsening (8% versus 44%); (6) mean quality of life points in which lower is better (13.89 versus 27.89); and (7) mean cost of care per year (216,700). These differences were highly significant in favor of emergency portacaval shunt (all p < 0.001).
Emergency portacaval shunt was strikingly superior to endoscopic sclerotherapy as well as to the combination of endoscopic sclerotherapy and rescue portacaval shunt in regard to all outcome measures, specifically bleeding control, survival, incidence of portal-systemic encephalopathy, improvement in liver function, quality of life, and cost of care. These results strongly support the use of emergency portacaval shunt as the first line of emergency treatment of bleeding esophageal varices in cirrhosis
International genome-wide meta-analysis identifies new primary biliary cirrhosis risk loci and targetable pathogenic pathways.
Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist
Nature’s nations: the shared conservation history of Canada and the USA
Historians often study the history of conservation within the confines of national borders, concentrating on the bureaucratic and political manifestations of policy within individual governments. Even studies of the popular expression of conservationist ideas are generally limited to the national or sub-national (province, state, etc.) scale. This paper suggests that conservationist discourse, policy and practice in Canada and the USA were the products of a significant cross-border movement of ideas and initiatives derived from common European sources. In addition, the historical development of common approaches to conservation in North America suggests, contrary to common assumptions, that Canada did not always lag behind the USA in terms of policy innovation. The basic tenets of conservation (i.e. state control over resource, class-based disdain for subsistence hunters and utilitarian approaches to resource management) have instead developed at similar time periods and along parallel ideological paths in Canada and the USA
Cooperative Assembly of Metal Nitrate and Citric Acid with Block Copolymers: Role of Carbonate Conversion Temperature on the Mesostructure of Ordered Porous Oxides
The
conversion of cooperatively assembled metal nitrate, citric
acid, and an amphiphilic block copolymer, polyÂ(methoxypolyÂ[ethylene
glycol methacrylate])-<i>block</i>-polyÂ(butyl acrylate),
films to their associated carbonate is investigated using Fourier
transform infrared spectroscopy (FTIR) and spectroscopic ellipsometry
for both cobalt and copper. The processing conditions associated with
the formation of the carbonate significantly impact the mesostructure
generated. Ex situ FTIR measurements tracked the carbonate formation
and consumption of citric acid to elucidate the kinetics of the reactions
and were compared to the evolution in the film thickness and refractive
index by in situ spectroscopic ellipsometry. From ellipsometry, the
initial rate of thickness change appears to follow an Arrhenius temperature
dependence with the apparent activation energy for Co (43 kJ/mol)
approximately double that for Cu (23 kJ/mol). These data elucidating
the reaction kinetics enable optimization of the temperature and reaction
time for improved properties and decreased fabrication time. The temperature
utilized to form the carbonate impacts the mesostructure that develops
and the porosity in the resultant oxide film. The optimum temperature
to maximize the porosity of the oxide films is an intermediate carbonate
formation temperature where the rate of conversion is not too fast
to disrupt the nanostructure, but the final conversion is sufficiently
high to provide thermal resilience to the framework through calcination.
This knowledge enables fabrication of ordered mesoporous oxides with
porosities in excess of 60%