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❶Pill Varizen||Pill Varizen | Pill Varizen|Background Nonselective beta-adrenergic blockers decrease portal pressure and prevent variceal hemorrhage. Their effectiveness in preventing varices is unknown.|Beta-Blockers to Prevent Gastroesophageal Varices in Patients with Cirrhosis|]

N Engl J Med ; Nonselective beta-adrenergic blockers decrease portal pressure and prevent variceal hemorrhage. Their effectiveness Pill Varizen preventing varices is unknown. Full Pill Varizen of Background We randomly assigned patients Pill Varizen cirrhosis and portal hypertension minimal hepatic venous pressure gradient Hyperpigmentierung ist Haut of 6 mm Hg Pill Varizen receive timolol, a nonselective Pill Varizen patientsor placebo patients.

The primary end point was the development of gastroesophageal varices Pill Varizen variceal hemorrhage. Endoscopy and HVPG Pill Varizen were repeated yearly. Full Text of Methods During a median follow-up of Serious adverse events were more common among patients in the timolol group than among those in the placebo group 18 percent Pill Varizen. Varices developed less frequently among patients with a baseline HVPG of less than 10 mm Hg and among Pill Varizen in whom the HVPG decreased by more than 10 percent at one year and more frequently among those in whom the HVPG increased by more than 10 percent at one year.

Full Text of Results Nonselective beta-blockers are ineffective in preventing varices in unselected patients with cirrhosis and portal hypertension and are associated with an increased Pill Varizen of adverse events. Full Text of Discussion Randomized, controlled trials have demonstrated that nonselective beta-blockers prevent variceal hemorrhage in patients with varices. In fact, an experimental study demonstrated that beta-blockers prevent the development of portosystemic collateral vessels.

The study was an investigator-initiated, randomized, double-blind, placebo-controlled, clinical trial conducted at four sites. The protocol was approved by the institutional click board at each site, and all patients gave written informed consent.

Timolol maleate Blocadren and placebo were provided by Merck; Merck did not participate in any other aspect of the study, including study design, data analysis, and manuscript preparation.

Patients were enrolled between August and March Pill Varizen followed until September Eligible patients had cirrhosis and portal hypertension, as defined by an HVPG of at least 6 mm Hg; did not have gastroesophageal varices; and were older than 18 years and younger than 75 years of age.

The diagnosis of cirrhosis was either Pill Varizen or clinically suspected and confirmed by the finding of an HVPG of 10 mm Hg or greater. The absence of gastroesophageal varices was determined unanimously at endoscopy by two staff endoscopists who Pill Varizen present during the entire Pill Varizen and who Pill Varizen the procedure independently. Exclusion criteria included ascites requiring diuretics, hepatocellular carcinoma, splenic- or portal-vein thrombosis, concurrent illnesses expected to decrease life expectancy to less than one year, the use of any drug or procedure affecting splanchnic hemodynamics or portal pressure, primary biliary cirrhosis or primary sclerosing cholangitis, contraindications to beta-blocker therapy, pregnancy, or alcohol intake during the dose-titration phase.

Of patients screened for varices, 63 percent had none. Of these patients, 43 percent were included in the study. The remaining were excluded Pill Varizen the following reasons: The dose of timolol Pill Varizen placebo to be used during the study was determined bestanden Geschwüren each patient before randomization during a titration period in which open-label timolol was administered orally.

The Pill Varizen dose of timolol was 5 mg per day and was increased by 5 mg every three days until one of the following occurred: After the titration period, patients were randomly assigned to receive timolol or an identical-appearing placebo tablet. The randomization code was generated Pill Varizen computer for each participating center. Patients were stratified according to the cause of cirrhosis alcoholic vs.

An alcoholic cause was defined as a long-standing history of alcohol Pill Varizen exceeding 60 g per day. In patients with a dual alcoholic and viral cause, the classification of cirrhosis was based on the clinical and histologic findings.

Patients were assessed clinically at baseline, Pill Varizen and three months after randomization, and every three months thereafter. At each visit, Kräuter Thrombophlebitis heart rate, pill count, occurrence of adverse events, and alcohol consumption were determined and blood was obtained for hematologic and biochemical measurements.

At baseline and every year thereafter, upper endoscopy was performed and HVPG was measured as described elsewhere. The primary end points were visit web page development of varices or variceal hemorrhage as identified unanimously at endoscopy by two staff endoscopists who were present during the entire procedure and who evaluated the procedure independently.

Varices were defined by the presence of one of the following: Variceal hemorrhage Pill Varizen defined Pill Varizen any hematemesis or melena in a patient in whom endoscopy showed active bleeding from an esophageal or gastric varix, an esophageal or gastric varix with an adherent clot, or varices but no other source Pill Varizen bleeding.

Secondary end points were the development of ascites or encephalopathy, liver transplantation, or death. Data collection was terminated article source treatment was considered to have Pill Varizen when a patient reached the primary end point, underwent liver transplantation, or died.

Http:// adverse event was any event that required a diagnostic or therapeutic intervention. All adverse events, regardless of their possible association with the disease or study Pill Varizen, were recorded.

An adverse event was judged severe if learn more here was considered to endanger the health or safety of the patient.

Members of a data and safety monitoring board were appointed by Pill Varizen National Institute of Diabetes and Digestive and Kidney Diseases and met every six see more to review the progress of the study and accumulated data. According to the protocol, one interim analysis was performed on October 26,after all patients had been enrolled. At that time, the data and safety monitoring board was empowered to recommend termination of the study on the basis of concern about safety or in the presence of sufficient evidence to indicate that timolol was statistically superior to placebo.

The board voted unanimously to recommend continuation of Pill Varizen trial. We estimated that treatment with Pill Varizen would reduce the four-year cumulative probability Übung Schere mit Krampfadern varices from 50 percent the rate without treatment 6,7 to 30 percent, given a statistical power of 80 percent to detect an absolute difference of 20 percent between the placebo and timolol groups at a two-sided alpha level of 0.

We estimated that the study would require patients, and learn more here then increased this amount by 10 percent to account for Pill Varizen loss Pill Varizen patients to follow-up, yielding a total of patients.

All analyses Pill Varizen conducted according to the intention-to-treat principle. Actuarial probabilities were calculated Pill Varizen to the Kaplan—Meier method and compared with use of the log-rank test. Data were censored when the primary end point was reached, at the time of transplantation or death, or at the time of the last visit, whichever occurred first.

A Cox proportional-hazards model was used to identify the variables that Pill Varizen explained the variability in the rates of primary end points, treatment failure, and survival. Calculations were performed with the use of the SAS statistical software package. A total of patients underwent randomization: The median time from screening endoscopy to randomization was 29 days range, 8 to There were no significant differences between groups in the proportion of patients with alcohol-induced cirrhosis or in the HVPG.

The median Child—Pugh score was 5 range, 5 to 9; scores can range from 5 to 15, with higher scores indicating more severe liver disease. The median duration of follow-up was The median daily dose of timolol was The dose had to be reduced in 29 patients 26 in the timolol group vs.

Adherence to treatment was considered adequate if the pill count showed more Pill Varizen 70 percent adherence; this degree of adherence was achieved in 86 patients in the timolol group 80 percent and 88 patients in the placebo group 84 percent.

A total of 84 patients reached the primary end point of varices or variceal bleeding: Cumulative percentages of patients who did not reach the Pill Varizen end point at 12, 24, 36, and 60 months were 91 percent, 86 percent, 79 percent, and 60 percent, respectively, in the timolol group and 97 percent, 82 percent, 78 percent, and 57 percent, respectively, in the placebo group.

The rates of the primary end point both overall and for the timolol group did not differ significantly when patients who had a reduction in the dose or stopped treatment were compared with those who did not have a reduction in the dose or discontinue treatment data not shown. Hepatocellular carcinoma, which was not considered an end point of the study, occurred in eight patients in the timolol group and six patients in the placebo group.

A comparison of Pill Varizen 84 patients who reached the primary end point with the patients who did not reach the primary end point revealed that Pill Varizen following baseline variables differed at a Pill Varizen value of less than 0.

The incidence Pill Varizen moderate or severe adverse events was higher in the timolol group than Pill Varizen the placebo group Pill Varizen percent [52 patients] vs. None of the Pill Varizen were fatal. The average reduction in the heart rate from baseline was 17 percent in the timolol group. HVPG measurements were repeated at one year in patients 72 in the timolol group and 82 in the placebo group.

As compared with baseline values, the HVPG decreased by a median of 1. Reductions in the HVPG of more than 10 percent Figure 3Bmore than 15 percent, and more than 20 percent here all associated with a significantly lower incidence of the primary end point.

Conversely, an increase in the HVPG by more than 10 percent also correlated with an increased likelihood of reaching the end point Figure 3C. However, there were no significant differences between groups in the increases in HVPG. In this placebo-controlled study, treatment with a nonselective article source, timolol, did not prevent gastroesophageal varices in unselected patients with cirrhosis and Pill Varizen hypertension and was associated with an increased number of adverse Pill Varizen. A previous French study of the Pill Varizen of varices showed that, in patients without varices or Braunschweig Varison small varices, the development of large varices was more frequent among propranolol-treated patients than among patients who received placebo.

Most of the patients had small varices, and significant differences were confined to this subgroup of We used timolol, a potent nonselective beta-blocker, 10 and as shown in patients with essential hypertension, 11 once-daily dosing was sufficient to maintain the reduction in heart rate for at least 24 hours.

The average decrease in heart rate in the timolol group was 17 percent. This reduction is smaller than the range of 20 to Pill Varizen percent median, 24 percent reported in studies of beta-blockers in the primary prophylaxis of variceal hemorrhage and is probably due Pill Varizen the lower baseline heart rate median, 73 beats per minute in our study than in primary-prophylaxis studies of patients with varices median, 80 beats per minute 9, or secondary-prophylaxis studies of patients with varices median, 84 beats per minute.

The lack of an overall significant change in the HVPG may partly explain our negative results. Although it is possible that positive results could have been obtained if the dose of timolol had been higher, drug intolerance limited our ability to increase the dose further in this group of patients with compensated cirrhosis, most of whom were reluctant to tolerate even minimal side effects.

A major finding of our study was the effect of baseline HVPG on outcomes. This finding supports the definition of clinically significant portal hypertension as an HVPG of at least 10 Pill Varizen Hg. We confirmed the importance of lowering portal die Auswirkungen fetalen Blutfluss shown in previous studies of patients with more advanced cirrhosis. An important finding was that more patients Pill Varizen the timolol group than in the placebo group had these favorable HVPG responses, indicating that timolol had a beneficial Pill Varizen, but one that was wie Thrombophlebitis Venen der unteren Extremitäten behandeln sufficient to tip the balance in favor of beta-blockers.

Conversely, we also found that increases in portal pressure were associated with the development of varices, although timolol apparently had no ability to prevent this increase in HVPG.

In conclusion, even though the role of nonselective beta-blockers in preventing variceal hemorrhage in patients who already have varices is well Pill Varizen, we found that nonselective beta-adrenergic blockers did not prevent varices in patients with cirrhosis and portal hypertension.

The use of beta-blockers cannot be widely recommended in this population because of its association with an increased incidence of serious side effects. However, even in this population of patients with compensated cirrhosis, we have confirmed the predictive value of baseline HVPG levels and of a Pill Varizen reduction in the HVPG by more than 10 percent, the latter of which should be the goal in the pharmacologic prevention of gastroesophageal varices.

Supported by a grant Pill Varizento Dr. We are indebted to the endoscopists, interventional radiologists, pathologists, study coordinators, nurses, and fellows at each of the four participating centers who were part of the Portal Hypertensive Collaborative Group and who contributed to the performance and successful completion of the study; and to A. Rand of the external advisory data and safety monitoring board.

Address reprint requests to Dr. Increased portal venous resistance hinders portal pressure reduction during the administration of beta-adrenergic blocking agents in a portal hypertensive model. Effect of selective blockade of beta-2 adrenergic receptors on portal and systemic hemodynamics in a portal hypertensive rat model.

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