Early identification of haemodynamic response to pharmacotherapy is essential for primary prophylaxis of variceal bleeding in patients with 'high-risk' varices

Background: A beta-blocker is recommended for primary prophylaxis of variceal bleeding; however, only one-third have hepatic venous pressure gradient (HVPG) response. The role of addition of isosorbide-5-mononitrate (ISMN) to beta-blocker and benefits of HVPG-guided 'a la carte' approach remain unclear. Aim: To determine the benefits of HVPG-guided pharmacotherapy in primary prophylaxis of variceal bleeding using beta-blocker and ISMN. Patients and methods: Consecutive patients of cirrhosis, with high-risk varices, with no previous variceal bleeding were included. After baseline HVPG, patients received incremental propranolol to achieve HR of 55/min. After one-month, HVPG was repeated to determine response (<12 mmHg or ≥20% reduction). ISMN was added in nonresponders and HVPG repeated. Patients were followed up for 24 months. Results: Of 56 patients (age 47 ± 13, males 79%) from 89 eligible patients, 21 (38%) responded to beta-blocker alone. Six additional patients responded to combination. Thus, overall 48% (27/56) patients responded. Variceal bleeding occurred in seven of 56 (13%) patients [one of 27 (4%) responder, five of 23 (22%) nonresponders and one of six (17%) with unknown response; P = N.S.]. The actuarial probability of variceal bleeding at median 24 months was 4% in responders and 22% in nonresponders (P < 0.05). Ten (18%) patients developed adverse effects to propranolol and six of 35 (17%) to nitrates requiring dose reduction. Risk factors of variceal bleed were grade IV varices and haemodynamic nonresponse. Conclusions: For primary prophylaxis, a beta-blocker is effective in 38% and addition of ISMN raises the response rate to about half of patients. The HVPG-guided 'a la carte' approach may be considered for these patients

Histological subclassification of cirrhosis based on histological-haemodynamic correlation

Background: Determining a relationship between specific histological parameters in cirrhosis and hepatic venous pressure gradient can be used to subclassify cirrhosis. Aim: To determine the relationship between hepatic venous pressure gradient and specific histological parameters in cirrhosis. Methods: Forty-seven patients (mean age: 46.2 ± 13.6 years; 36 male) with biopsy-proven cirrhosis and hepatic venous pressure gradient measurements within 1 month of biopsy were studied. The following histological parameters were scored semiquantitatively: nodule size, loss of portal tracts and central veins, portal inflammation, periportal inflammation, bile duct proliferation, lobular inflammation, ballooning, fatty change, cholestasis and septal thickness. Results: On multiple ordinal regression analysis, small nodule size (odds ratio: 21.0; 95% confidence interval: 2.1-208.2, P = 0.009) and thick septa (OR: 42.6; CI: 2.3-783.7, P = 0.011) were significantly associated with the presence of clinically significant portal hypertension. A score was assigned to each of the two parameters (nodule size: large = 1, medium = 2, small = 3 and septal thickness: thin = 1, medium = 2, thick = 3). Two subcategories were devised based on the composite score: category A (n = 12): score 1-3 and category B (n = 35): score 4-6. On ordinal regression, subcategory B (OR: 15.5; CI: 3.3-74.2, P = 0.001) was significantly associated with clinically significant portal hypertension. Conclusion: Small nodularity and thick septa are independent predictors of the presence of clinically significant portal hypertension

Analysis of cerebrospinal fluid adenosine deaminase level in tuberculous meningitis and validation of sensitivity and specificity

Background: Tuberculous meningitis is an important cause of morbidity and mortality in developing countries especially in India. The mortality associated with tuberculous meningitis is very high if not detected early and meticulous treatment is not given. CSF analysis and imaging are the most commonly used tools for diagnosis of meningitis. But these are often inadequate in making a definitive diagnosis. CSF Adenosine Deaminase estimation (ADA) is useful in differentiation of tuberculous meningitis from non-tuberculous meningitis. Though few studies have proved efficacy of Adenosine Deaminase level for the diagnosis, studies to assess the sensitivity and specificity of ADA levels were limited. This study was conducted to assess its usefulness and to validate the sensitivity and specificity of ADA level in tuberculous meningitis (TBM).Methods: This was a prospective study conducted at Academy of Medical Sciences, Pariyaram for a period of 18 months from December 2013 to June 2015, Adenosine deaminase level was studied in the cerebrospinal fluid of 50 patients who got admitted with symptoms and signs of meningitis in the medical wards and intensive care units who fulfilled the inclusion criteria.Results: In this study 50 patients were diagnosed clinically and with CSF analysis as meningitis. The mean cerebrospinal fluid adenosine deaminase activity was 23.08+17.5in Tuberculous meningitis 3.8 +1.92U/l in Bacterial meningitis and 4.8+2.3U/l in Viral meningitis. The adenosine deaminase activity in Tuberculous meningitis cases were significantly higher than non-tuberculous meningitis. The sensitivity and specificity of this test for diagnosis of tuberculous meningitis was 90% and 100% respectively with ADA value of more than 10U/L.Conclusions: This study found out that estimation of CSF Adenosine level is a very useful test for the diagnosis of tuberculous meningitis. The sensitivity and specificity attained in this study were comparable to other studies. This study also found out that ADA estimation is very useful in distinguishing tuberculous and viral meningitis

The Development of Chemically Vapor Deposited Mullite Coatings for the Corrosion Protection of SiC

Crystalline mullite coatings have been chemically vapor deposited onto SiC substrates to enhance the corrosion and oxidation resistance of the substrate. Current research has been divided into three distinct areas: (1) Development of the deposition processing conditions for increased control over coating`s growth rate, microstructure, and morphology; (2) Analysis of the coating`s crystal structure and stability; (3) The corrosion resistance of the CVD mullite coating on SiC

Investment under ambiguity with the best and worst in mind

Recent literature on optimal investment has stressed the difference between the impact of risk and the impact of ambiguity - also called Knightian uncertainty - on investors' decisions. In this paper, we show that a decision maker's attitude towards ambiguity is similarly crucial for investment decisions. We capture the investor's individual ambiguity attitude by applying alpha-MEU preferences to a standard investment problem. We show that the presence of ambiguity often leads to an increase in the subjective project value, and entrepreneurs are more eager to invest. Thereby, our investment model helps to explain differences in investment behavior in situations which are objectively identical

Collision geometry scaling of Au+Au pseudorapidity density from sqrt(s_NN) = 19.6 to 200 GeV

The centrality dependence of the midrapidity charged particle multiplicity in Au+Au collisions at sqrt(s_NN) = 19.6 and 200 GeV is presented. Within a simple model, the fraction of hard (scaling with number of binary collisions) to soft (scaling with number of participant pairs) interactions is consistent with a value of x = 0.13 +/- 0.01(stat) +/- 0.05(syst) at both energies. The experimental results at both energies, scaled by inelastic p(pbar)+p collision data, agree within systematic errors. The ratio of the data was found not to depend on centrality over the studied range and yields a simple linear scale factor of R_(200/19.6) = 2.03 +/- 0.02(stat) +/- 0.05(syst).Comment: 5 pages, 4 figures, submitted to PRC-R

Centrality and pseudorapidity dependence of elliptic flow for charged hadrons in Au+Au collisions at sqrt(sNN) = 200 GeV

This paper describes the measurement of elliptic flow for charged particles in Au+Au collisions at sqrt(sNN)=200 GeV using the PHOBOS detector at the Relativistic Heavy Ion Collider (RHIC). The measured azimuthal anisotropy is presented over a wide range of pseudorapidity for three broad collision centrality classes for the first time at this energy. Two distinct methods of extracting the flow signal were used in order to reduce systematic uncertainties. The elliptic flow falls sharply with increasing eta at 200 GeV for all the centralities studied, as observed for minimum-bias collisions at sqrt(sNN)=130 GeV.Comment: Final published version: the most substantive change to the paper is the inclusion of a complete description of how the errors from the hit-based and track-based analyses are merged to produce the 90% C.L. errors quoted for the combined results shown in Fig.

Energy dependence of elliptic flow over a large pseudorapidity range in Au+Au collisions at RHIC

This paper describes the measurement of the energy dependence of elliptic flow for charged particles in Au+Au collisions using the PHOBOS detector at the Relativistic Heavy Ion Collider (RHIC). Data taken at collision energies of $\sqrt{s_{_{NN}}} =$ 19.6, 62.4, 130 and 200 GeV are shown over a wide range in pseudorapidity. These results, when plotted as a function of $\eta'=|\eta|-y_{beam}$, scale with approximate linearity throughout $\eta'$, implying no sharp changes in the dynamics of particle production as a function of pseudorapidity or increasing beam energy.Comment: 5 pages, 4 figure

Elliptic Flow in Au+Au Collisions at RHIC

Elliptic flow is an interesting probe of the dynamical evolution of the dense system formed in the ultrarelativistic heavy ion collisions at the Relativistic Heavy Ion Collider (RHIC). The elliptic flow dependences on transverse momentum, centrality, and pseudorapidity were measured using data collected by the PHOBOS detector, which offers a unique opportunity to study the azimuthal anisotropies of charged particles over a wide range of pseudorapidity. These measurements are presented, together with an overview of the analysis methods and a discussion of the results.Comment: Presented at Hot Quarks 2004; 7 pages, 6 figure