Comparing Feto-Maternal Outcomes in Pregnant Women With Normal and Abnormal Liver Function Tests: A Prospective Observational Study.

INTRODUCTION: Pregnant women with abnormal liver function tests (LFTs) require proper evaluation and timely management to reduce maternal and fetal morbidity and mortality. OBJECTIVE: The present study was done with the objective of determining feto-maternal outcomes in antenatal women with abnormal LFTs and comparing them with antenatal women having normal liver function. The prevalence and possible causes of derangements in LFT were also identified. METHOD: Pregnant women referred to an antenatal clinic for several reasons pertaining to abnormal liver functions, and those admitted to the labor room for delivery with abnormal LFTs were included in the study. The pregnant women with abnormal LFT were studied prospectively, and they were compared with pregnant women having normal LFT. The fetal and maternal outcomes were also noted. RESULTS:  The pregnant women attending the antenatal clinic with a history of pruritus, abdominal pain, jaundice, nausea/vomiting, hypertension ascites, etc. and delivered at our facility were evaluated. One hundred and eight women had abnormal LFT defined by criteria laid down in material and methods. Eighty-seven women with normal LFT were taken for comparison. In the abnormal LFT, the main cause was intrahepatic cholestasis of pregnancy (IHCP). There were 6 (5.5%) maternal deaths in this group and none in the normal LFTs. There were 6 (5.6%) fetal deaths and 4 (4.6%) in the other group (p-value=1). The prevalence of abnormal LFT was 9.11% throughout pregnancy. Increased bilirubin and alkaline phosphatase (ALP) were significantly correlated with maternal mortality, while gestational age at birth, presence of meconium, appearance, pulse, grimace, activity, and respiration (APGAR) score, maternal mortality, and raised alkaline phosphatase level were found to be significantly associated with fetal mortality. CONCLUSION: Patients with abnormal LFT were significantly associated with maternal morbidity and mortality. However, fetal outcomes in patients with abnormal and normal LFT were similar. Hyperbilirubinemia and raised alanine aminotransferase (ALT) were significant predictors of maternal mortality.

Baseline serum cystatin C as a marker of acute kidney injury in patients with acute-on-chronic liver failure.

BACKGROUND: A creatinine-based estimation of the renal function lags behind the onset of disease process. Cystatin C is a new marker for acute kidney injury (AKI). However, data are limited in patients with acute-on-chronic liver failure (ACLF). We evaluated serum cystatin C as an early predictor of AKI in patients with ACLF. METHODS: In a prospective observational study, patients with ACLF and normal serum creatinine level were included in the study. Serum cystatin C was analyzed with the development of AKI and the disease outcome. RESULT: Forty-seven patients (mean age: 43.26±16.34 years; male:female: 2.35:1) were included in the study. AKI developed in 34% of patients during the hospital stay. Receiver operating characteristic (ROC) curve analysis revealed that the best cutoff for baseline cystatin C was 1.47 mg/L with a sensitivity of 0.94 and specificity of 0.68. The cystatin C ((area under the curve [AUC]=0.853) performance was better than that of the creatinine (AUC=0.699), Child-Turcotte-Pugh (CTP) (AUC=0.661), and model for end-stage liver disease-sodium (MELD-Na) (AUC=0.641). In the univariate analysis, age, platelet count, creatinine, estimated glomerular filtration rate (eGFR)-modification of diet in renal disease (MDRD), cystatin C, and estimated glomerular filtration rate-serum cystatin C (eGFRcysC) were significantly associated with AKI in ACLF patients. Cystatin C was an independent positive predictor of AKI. Cystatin C was positively correlated with the MELD-Na scores (r=0.374 and p=0.009). CONCLUSION: Our study supports previous studies reporting that serum cystatin C is a better predictor for AKI development compared to serum creatinine. Cystatin C may be used as an early marker for new-onset AKI in hospitalized patients with ACLF.

Short-term mortality in patients with cirrhosis of the liver and acute kidney injury: A prospective observational study.

INTRODUCTION: Renal failure is a common and severe complication of cirrhosis and confers poor prognosis. Serum creatinine is the most practical biomarker of renal function. Serum creatinine estimation in cirrhosis of the liver is affected by decreased formation, increased tubular secretion, increased volume of distribution, and interference by elevated bilirubin. Studies on the prognosis of cirrhotic patients using creatinine kinetics as a definition of acute kidney injury (AKI) proposed by the International Ascites Club are limited. METHODS: In this single-center prospective observational study, decompensated cirrhotics with AKI defined by the International Ascites Club as the rise of serum creatinine ≥ 0.3 mg/dL within 48 h of admission or increase of serum creatinine ≥ 50% from stable baseline creatinine over the previous 3 months were followed and assessed for the development of complications during hospital course and in-hospital and 30-day mortality. RESULTS: AKI developed in 142 out of 499 (28.45%) patients with cirrhosis. Twenty patients were excluded. The most common etiology of cirrhosis was alcohol (n = 64, 52%), and ascites was present in 115 (94%) patients. Eighty-two (67.21%) patients presented with AKI at the time of admission. Thirty-day mortality was 46.72% (57/122 patients). Hepatorenal syndrome had the highest mortality followed by AKI related to infection. Presence of jaundice and hepatic encephalopathy (HE) was associated with poor survival with adjusted hazard ratio of 3.54 and 2.17, respectively. On bivariate logistic regression analysis, jaundice, HE, type of AKI, AKI stage at maximum creatinine, bilirubin, serum glutamic oxaloacetic transaminase (SGOT), international normalized ratio (INR), and Child-Turcotte-Pugh (CTP) and model for end-stage liver disease (MELD) scores were predictors of mortality (p < 0.05). Sensitivity, specificity, and accuracy of MELD > 29 and CTP score > 11 were 75.44%, 82%, and 78.70% and 66.67%, 81.54%, and 74.60%, respectively for predicting 30-day mortality. CONCLUSION: Development of AKI as defined by the International Ascites Club in cirrhosis confers high short-term mortality. Jaundice, HE, AKI stage, creatinine at enrollment, bilirubin, CTP, and MELD score were the predictors of mortality. Bullet points of the study highlights What is already known? • Renal failure is a common and severe complication of cirrhosis. • Serum creatinine is the most practical biomarker of renal function but it has many limitations in cirrhotic patients. • Creatinine kinetics-based definition of acute kidney injury (AKI) was proposed by the International Ascites Club. What is new in this study? • Short-term mortality (30 days) in decompensated cirrhotic patients with AKI as defined by the International Ascites Club using creatinine kinetics was high. • AKI due to hepatorenal syndrome (HRS) has the highest short-term (30 days) mortality followed by AKI due to infection in decompensated cirrhosis. • Detection of AKI using creatinine kinetics-based definition may prompt an early appropriate intervention. What are the future clinical and research implications of study findings? • Creatinine kinetics-based definition of AKI diagnose renal injury at an earlier stage; an appropriate intervention should be initiated at the earliest in these patients to improve patient survival.

Quantification of node importance in rain gauge network: influence of temporal resolution and rain gauge density.

Rain gauge network is important for collecting rainfall information effectively and efficiently. Rain gauge networks have been studied for several decades from a range of hydrological perspectives, where rain gauges with unique or non-repeating information are considered as important. However, the problem of quantification of node importance and subsequent identification of the most important nodes in rain gauge networks have not yet been extensively addressed in the literature. In this study, we use the concept of the complex networks to evaluate the Indian Meteorological Department (IMD) monitored 692 rain gauge in the Ganga River Basin. We consider the complex network theory-based Degree Centrality (DC), Clustering Coefficient (CC) and Mutual Information (MI) as the parameters to quantify the rainfall variability associated with all the rain gauges in the network. Multiple rain gauge network scenario with varying rain gauge density (i.e. Network Size (NS) = 173, 344, 519, and 692) and Temporal Resolution (i.e. TR = 3 hours, 1 day, and 1 month) are introduced to study the effect of rain gauge density, gauge location and temporal resolution on the node importance quantification. Proxy validation of the methodology was done using a hydrological model. Our results indicate that the network density and temporal resolution strongly influence a node's importance in rain gauge network. In addition, we concluded that the degree centrality along with clustering coefficient is the preferred parameter than the mutual information for the node importance quantification. Furthermore, we observed that the network properties (spatial distribution, DC, Collapse Correlation Threshold (CCT), CC Range distributions) associated with TR = 3 hours and 1 day are comparable whereas TR = 1 month exhibit completely different trends. We also found that the rain gauges situated at high elevated areas are extremely important irrespective of the NS and TR. The encouraging results for the quantification of nodes importance in this study seem to indicate that the approach has the potential to be used in extreme rainfall forecasting, in studying changing rainfall patterns and in filling gaps in spatial data. The technique can be further helpful in the ground-based observation network design of a wide range of meteorological parameters with spatial correlation.

Comparison of concomitant therapy versus standard triple-drug therapy for eradication of Helicobacter pylori infection: A prospective open-label randomized controlled trial.

INTRODUCTION: Resistance to commonly used antibiotics against Helicobacter pylori (H. pylori) is increasing rapidly leading to lower success of traditional triple therapy to eradicate H. pylori infection. So, search for a new regimen as the first-line therapy of H. pylori infection is needed. AIM: In this study, we compared the efficacy of 14-day concomitant therapy and 14-day triple therapy for the eradication of H. pylori infection. METHOD: In this open-labeled prospective trial, patients with H. pylori infection were randomized to concomitant therapy (pantoprazole 80 mg, amoxicillin 2000 mg, clarithromycin 1000 mg, and metronidazole 1000 mg daily in divided doses) and triple therapy (pantoprazole 80 mg, amoxicillin 2000 mg, and clarithromycin 1000 mg daily in divided doses). Duration of treatment was 14 days. Gastric biopsy was done 10-12 weeks after completion of therapy to confirm H. pylori eradication. RESULT: The eradication rate achieved with the concomitant therapy was significantly greater than that obtained with the triple therapy. Per-protocol eradication rates of concomitant and triple therapy were 77% and 58.3% (p = 0.028), respectively. Intention-to-treat eradication rates of concomitant and triple therapy were 70.1% and 49.3% (p = 0.013), respectively. Both the treatment regimens were well tolerated. CONCLUSION: Although the rate of eradication of H. pylori infection with  concomitant therapy was higher than that with triple therapy, the rate of concomitant therapy was still less than expected.

Optimal cut-off value of fecal calprotectin for the evaluation of ulcerative colitis: An unsolved issue?

INTRODUCTION: There is variability in the fecal calprotectin (FCP) cut-off level for the prediction of ulcerative colitis (UC) disease activity and differentiation from irritable bowel disease (IBS-D). The FCP cut-off levels vary from country to country. AIMS: We aimed to assess FCP as a marker of disease activity in patients with UC. We determined the optimal FCP cut-off value for differentiating UC and IBS-D. METHODS: In a prospective study, we enrolled 76 UC and 30 IBS-D patients. We studied the correlation of FCP with disease activity/extent as well as its role in differentiating UC from IBS-D. We also reviewed literature regarding the optimal FCP cut-off level for the prediction of disease activity and differentiation from IBS-D patients. RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 158 µg/g) for the prediction of complete mucosal healing (using Mayo endoscopic subscore) were 90, 85, 94.7, and 73.3%, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of FCP (cut-off level, 425 µg/g) for the prediction of inactive disease (Mayo Score ≤ 2) were 94.3, 88.7, 86.2, and 95.4%, respectively. We also found a FCP cut-off value of 188 µg/g for the differentiation of UC from IBS-D. CONCLUSIONS: The study reveals the large quantitative differences in FCP cut-off levels in different study populations. This study demonstrates a wide variation in FCP cut-off levels in the initial diagnosis of UC as well as in follow-up post-treatment. Therefore, this test requires validation of the available test kits and finding of appropriate cut-off levels for different study populations.

Comparison of continuous versus intermittent infusions of terlipressin for the control of acute variceal bleeding in patients with portal hypertension: An open-label randomized controlled trial.

BACKGROUND: Continuous infusion of terlipressin causes more stable reduction in portal venous pressure than intermittent infusion. The aim of the study was to compare the efficacy of continuous infusion vs. intermittent boluses of terlipressin to control acute variceal bleeding (AVB) in patients with portal hypertension. METHODS: Eighty-six consecutive patients with portal hypertension and AVB were randomized to receive either continuous intravenous infusion (Group A, n = 43) or intravenous boluses of terlipressin (Group B, n = 43). Group A received 1 mg intravenous bolus of terlipressin followed by a continuous infusion of 4 mg in 24 h. Group B received 2 mg intravenous bolus of terlipressin followed by 1 mg intravenous injection every 6 h. Upper gastrointestinal (UGI) endoscopy was done within 12 h of admission. Endoscopic variceal ligation (EVL) was done using a multi-band ligator. In both groups, treatment was continued up to 5 days. The primary endpoint was rebleeding or death within 5 days of admission. RESULTS: Patients in group A had lower rate of treatment failure (4.7%) as compared to patients in group B (20.7%) (p = 0.02). Within 6 weeks, four and eight patients died in group A and B, respectively (p = 0.21). Model for end-stage liver disease sodium (MELD-Na) score and continuous infusion of terlipressin showed significant relationship with treatment failure on multivariate analysis. CONCLUSIONS: Continuous infusion of terlipressin may be more effective than intermittent infusion to prevent treatment failure in patients with variceal bleeding. There is significant relationship between MELD-Na score [Odd ratio = 1.37 (95% CI-1.16 - 1.62), p-value < 0.001] and continuous infusion of terlipressin [Odd ratio = 0.18 (95% CI-0.037 - 0.91), p-value - 0.04] with treatment failure.

Post-endoscopic retrograde cholangiopancreatography pneumothorax: Report of two cases and literature review.

Pneumothorax is a very rare complication of endoscopic retrograde cholangiopancreatography. Here, we report two cases of pneumothorax following ERCP and sphincterotomy for choledocholithiasis. Patient was treated successfully with laprotomy and repair of a rent in the posterolateral wall of the second portion of duodenum. We also review the literature.

Effect of replenishment of vitamin D on survival in patients with decompensated liver cirrhosis: A prospective study.

AIM: To assess the vitamin D (VD) deficiency as a prognostic factor and effect of replenishment of VD on mortality in decompensated cirrhosis. METHODS: Patients with decompensated liver cirrhosis were screened for serum VD levels. A total of 101 VD deficient patients (< 20 ng/mL) were randomly enrolled in two groups: Treatment group (n = 51) and control group (n = 50). Treatment group received VD treatment in the form of intramuscular cholecalciferol 300000 IU as loading dose and 800 IU/d oral as maintenance dose along with 1000 mg oral calcium supplementation. The VD level, clinical parameters and survival of both the groups were compared for 6-mo. RESULTS: Prevalence of vitamin D deficiency (VDD) in decompensated CLD was 84.31%. The mean (SD) age of the patients in the treatment group (M:F: 40:11) and control group (M:F: 37:13) were 46.2 (± 14.93) years and 43.28 (± 12.53) years, respectively. Baseline mean (CI) VD (ng/mL) in control group and treatment group were 9.15 (8.35-9.94) and 9.65 (8.63-10.7), respectively. Mean (CI) serum VD level (ng/mL) at 6-mo in control group and treatment group were 9.02 (6.88-11.17) and 29 (23-35), respectively. Over the period of time the VD, calcium and phosphorus level was improved in treatment group compared to control group. There was non-significant trend seen in greater survival (69% vs 64%; P > 0.05) and longer survival (155 d vs 141 d; P > 0.05) in treatment group compared to control group. VD level had no significant association with mortality (P > 0.05). In multivariate analysis, treatment with VD supplement was found significantly (P < 0.05; adjusted hazard ratio: 0.48) associated with survival of the patients over 6-mo. CONCLUSION: VD deficiency is very common in patients of decompensated CLD. Replenishment of VD may improve survival in patients with decompensated liver cirrhosis.

Influence of Alluvial Morphology on Upscaled Hydraulic Conductivity.

The hydraulic conductivity of aquifers is a key parameter controlling the interactions between resource exploitation activities, such as unconventional gas production and natural groundwater systems. Furthermore, this parameter is often poorly constrained by typical data used for regional groundwater modeling and calibration studies performed as part of impact assessments. In this study, a systematic investigation is performed to understand the correspondence between the lithological descriptions of channel-type formation and the bulk effective hydraulic conductivities at a larger scale (Kxeff , Kyeff , and Kzeff in the direction of channel cross section, along the channel and in the vertical directions, respectively). This will inform decisions on what additional data gathering and modeling of the geological system can be performed to allow the critical bulk properties to be more accurately predicted. The systems studied are conceptualized as stacked meandering channels formed in an alluvial plain, and are represented as two facies. Such systems are often studied using very detailed numerical models. The main factors that may influence Kxeff , Kyeff , and Kzeff are the proportion of the facies representing connected channels, the aspect ratio of the channels, and the difference in hydraulic conductivity between facies. Our results show that in most cases, Kzeff is only weakly dependent on the orientations of channelized structures, with the main effects coming from channel aspect ratio and facies proportion.

A Single Center Experience Comparing Miniperc and Shockwave Lithotripsy for Treatment of Radiopaque 1-2 cm Lower Caliceal Renal Calculi in Children: A Prospective Randomized Study.

BACKGROUND AND PURPOSE: A prospective randomized study was performed comparing miniperc and shockwave lithotripsy (SWL) for treatment of radiopaque 1 to 2 cm lower caliceal renal calculi in children to evaluate safety and efficacy of these procedures. PATIENTS AND METHODS: Pediatric patients (<15 years) with a single radiopaque lower caliceal renal stone 1 to 2 cm undergoing treatment between March 2012 and September 2013 in our department were randomized into two groups-group A, miniperc; group B, SWL. The two groups were compared statistically regarding patient demographic profile, 3-month stone-free rate (SFR), re-treatment rates, auxiliary procedures, and complications. RESULTS: There were 106 patients enrolled in each group. The mean age (10.3 years vs 10.7 years, P=0.57) and stone size (12.7 mm vs 12.9 mm, P=0.31) were similar between group A and B patients. The re-treatment rate and auxiliary procedure rate were significantly greater in group B compared with group A (41.5% vs 2.8% and 14.2% vs 5.6%, respectively; P<0.001). The overall 3-month SFR was 94.3% for group A vs 83% for group B (P=0.03). The complication rate (20.7% vs 3.7%; P=0.01) and hospital stay (3.7 days vs 7.1 hours; P=0.01) was significantly higher in group A compared with group B. Blood transfusion was given in 10.3% patients in group A vs none in group B (P=0.01). CONCLUSIONS: Miniperc is more efficacious than SWL for treatment of radiopaque lower caliceal renal calculi 1 to 2 cm in children in terms of higher SFR and lesser auxiliary and re-treatment rates. Miniperc, however, resulted in more complication, operative time, radiation exposure, and hospital stay.

A Prospective Randomized Comparison Between Laparoscopic Ureterolithotomy and Semirigid Ureteroscopy for Upper Ureteral Stones >2 cm: A Single-Center Experience.

AIMS AND OBJECTIVES: The optimal management method of upper ureteral stones >2 cm is still a challenge. We performed a prospective randomized comparison between laparoscopic ureterolithotomy (LU) and ureteroscopic lithotripsy for upper ureteral calculus >2 cm to evaluate safety and efficacy of both procedures. MATERIALS AND METHODS: Between January 2010 and May 2012, 110 patients with a single radiopaque upper ureteral calculus >2 cm were included in the present study. Randomization was done in two groups-group A: LU was performed and group B: Ureteroscopy (URS) was performed using a 6/7.5F semirigid ureteroscope (Richard Wolf) with holmium laser intracorporeal lithotripsy. Statistical analysis was performed regarding demographic profile, success, retreatment, auxiliary procedure rates, and also complications. RESULTS: Out of the total 110 patients, 54 patients were enrolled in group A and 56 patients were enrolled in group B. Mean stone size was 2.3±0.2 cm in group A versus 2.2±0.1 cm in group B (p=0.52). The overall 3-month stone-free rate was (50/50) 100% for group A versus (38/50) 76% for group B (p=0.02). The retreatment rate was significantly greater in group B than group A (8% vs. 0%, respectively; (p=0.01). Auxiliary procedure rate was higher in group B than in group A (26% vs. 0% respectively; p=0.001). The complication rate was 12% in group A versus 26% in group B (p=0.001). CONCLUSIONS: For upper ureteral stones of size greater than 2 cm, LU has a greater stone clearance rate, comparable operating time, lesser need for auxiliary procedure, and complication rate as compared to URS.

A Prospective Randomized Comparison Between Shock Wave Lithotripsy and Flexible Ureterorenoscopy for Lower Caliceal Stones ≤2 cm: A Single-Center Experience.

AIMS AND OBJECTIVES: The optimal management method of lower caliceal calculi is still undefined. We performed a prospective randomized comparison to evaluate safety and efficacy of shock wave lithotripsy (SWL) and flexible ureteroscopy (RIRS) for lower caliceal calculus ≤2 cm. MATERIALS AND METHODS: Between December 2011 and January 2012, 195 patients with single radio-opaque lower caliceal calculi ≤2 cm were included in the study. Randomization was done into two groups-group A: SWL performed as an outpatient procedure using the electromagnetic lithotripter (Dornier compact delta) and group B: RIRS was performed using the 6F/7.5F flexible ureteroscope (Richard Wolf) with holmium laser intracorporeal lithotripsy. Demographic characteristics, success, retreatment, and auxiliary procedure rates and complications were analyzed statistically. RESULTS: Of 195 patients, 97 and 98 patients were enrolled in group A and B, respectively. Mean stone size was 12.1 mm in group A vs 12.3 mm in group B (p=0.52). The overall 3 month stone-free rate was (74/90) 82.2% for group A vs (78/90) 86.6% for group B (p=0.34); for stones <10 mm, it was (45/55) 84.9% for group A vs (43/51) 87.7% for group B (p=0.32) and for 10-20 mm stones, it was (29/35) 78.4% for group A vs (35/39) 85.4% for group B (p=0.12). Retreatment rate was significantly greater in group A compared with group B (61.1% vs 11.1%; p<0.001). Auxiliary procedure rate was comparable (21.1% vs 17.7%; p=0.45). The complication rate was 6.6% in group A vs 11.1% in group B (p=0.21). CONCLUSIONS: Both SWL and RIRS are safe and efficacious for lower caliceal calculi ≤20 mm. For stones <10 mm, SWL was less invasive and safer than RIRS with efficacy comparable to it. However, for 10-20 mm stones, RIRS was more effective, with lesser retreatment rate.

A prospective study on the effect of photoselective vaporization of prostate by 120-W high-performance system laser on sexual function.

INTRODUCTION: Photoselective vaporization of prostate (PVP) by 120W HPS laser emerged as an efficient, bloodless, and durable first line alternative to transurethral resection of prostate for treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic enlargement (BPE). In this study, we assessed effects of PVP by HPS laser on erectile function. MATERIAL AND METHODS: Between January 2012 and February 2014, 143 consecutive patients presenting with LUTS secondary to BPE, who underwent PVP by 120W HPS laser, were prospectively enrolled in the study. Patient's (Group A: International Index of Erectile Function-5 (IIEF-5) ≥19; Group B: IIEF <19) preoperative, perioperative and follow-up data were recorded. IIEF-5 was used to assess preoperative and postoperative erectile function at 1, 3, 6, and 12 months. Recorded data was analyzed statistically. RESULTS: Preoperative and perioperative data of the two groups were comparable. Significant improvement in IPSS, Qmax, QoL, and post void residual urine at 1, 3, 6 and 12 months were observed in both groups with no significant difference between them. Although IIEF-5 scores declined in both groups postoperatively (Group A: 21.06±1.21 to 19.84±1.55, P=0.43; Group B: 14.67±2.05 to 12.79±1.42, P=0.53), it was not statistically significant in either group. No significant difference was noted in IIEF-5 score between patients with or without indwelling catheter in either of the two groups. CONCLUSIONS: In patients undergoing PVP by 120W HPS laser for LUTS secondary to BPE, no significant effect was observed in sexual function at 1 year follow-up.

Effect of intraurethral dwell time of local anesthetic jelly on pain perception in men undergoing outpatient rigid cystoscopy: a randomized prospective study.

AIM: To determine optimum duration of intraurethral 2% lidocaine jelly for pain relief during outpatient rigid cystoscopy. MATERIALS AND METHODS: This prospective randomized study was conducted between June 2012 and November 2013. Four hundred consecutive adult males requiring diagnostic rigid cystoscopy were randomized into four groups depending on intraurethral 2% lidocaine jelly dwell time before rigid cystoscopy: jelly was instilled 5, 10, 15, and 20 minutes before start of the procedure in group A, B, C, and D patients, respectively. The patients' age, patient-reported preoperative anxiety score, patient-reported intraoperative pain score, the surgeon-reported patient's pain score, and the duration of rigid cystoscopy were recorded and analyzed. RESULTS: The mean age, patient-reported preoperative anxiety score, and duration of rigid cystoscopy were similar between the four groups with no significant difference noted between them. The least and highest mean patient-reported and surgeon-reported intraoperative pain scores were reported in group C (1.49±0.82 and 1.58±0.67) patients and group A (4.86±1.24 and 4.04±1.11) patients, respectively, while no significant difference was found in these scores between group C and D patients. CONCLUSION: For male patients undergoing diagnostic rigid cystoscopy, an intraurethral dwell time of 15 minutes (of 20 mL 2% lidocaine jelly) provided optimum pain relief.

Equal efficacy of endoscopic variceal ligation and propranolol in preventing variceal bleeding in patients with noncirrhotic portal hypertension.

BACKGROUND & AIMS: Variceal bleeding increases morbidity and mortality among patients with noncirrhotic portal hypertension (NCPH). Blockers of ß-adrenergic receptor signaling and endoscopic variceal ligation (EVL) have been used to prevent recurrence of bleeding, based on data from cirrhotic patients. We compared the efficacy and safety of the ß-blocker propranolol with that of EVL in preventing the recurrence of variceal bleeding in patients with NCPH. METHODS: Consecutive patients with NCPH with a history of variceal bleeding in the past 6 weeks were assigned randomly to groups treated every 3 weeks with EVL (n = 51) or propranolol (until they had a resting heart rate of 55 beats per minute or to a maximum of 320 mg/day; n = 50). Primary end points were recurrence of variceal bleeding or death. Secondary end points were complications of EVL in patients given EVL, variceal eradication after EVL, variceal recurrence after EVL, or a decrease in variceal grade in patients given propranolol. RESULTS: After a median follow-up period of 23 months, rates of recurrence of bleeding were similar between the groups (EVL, 23.5%; propranolol, 18%; P = .625). The actuarial probability of remaining free of bleeding recurrence was similar between the groups. No deaths occurred in either group. Of the patients given propranolol, 47% had a decrease in the grade of varices and none experienced bleeding. Adverse events were minor and comparable between groups (EVL, 12%; propranolol, 18%; P = .635). CONCLUSIONS: EVL was not more effective than the ß-blocker propranolol for the secondary prophylaxis of variceal bleeding in patients with NCPH.

Systemic and pulmonary hemodynamics in patients with extrahepatic portal vein obstruction is similar to compensated cirrhotic patients.

BACKGROUND: Patients with cirrhosis and portal hypertension exhibit a hyperdynamic circulation manifesting as increased cardiac output, heart rate and plasma volume; and decreased arterial blood pressure, systemic vascular resistance, and pulmonary vascular resistance. It is believed that these changes are related to both hepatocellular dysfunction and portal hypertension. However, the role of portal hypertension per se in producing these changes in circulation has not been clear. Extrahepatic portal vein obstruction (EHPVO), a vascular disorder of the liver characterized by cavernomatous transformation of the main portal vein, is an excellent model to study the role of portal hypertension per se in producing these changes because there is no hepatic dysfunction in EHPVO. The main aim of our study was, therefore, to evaluate alterations of systemic and pulmonary vascular systems in patients with EHPVO and compare them with patients with compensated cirrhosis. PATIENTS AND METHODS: Consecutive patients of EHPVO, 15 years or older, and past variceal bleeders were studied. For comparison, consecutive patients with compensated cirrhosis and history of variceal bleed, matched for variceal status, and body surface area were included. The hemodynamic studies included the measurements of cardiac index (by Fick's oxygen method), and systemic and pulmonary vascular resistance indices. RESULTS: Fifteen patients of EHPVO and same number of controls (compensated cirrhotics) were included in the study. The baseline parameters in the two groups were comparable. Both EHPVO patients and cirrhotics had similar values in all the measured systemic and pulmonary hemodynamic parameters. The median (range) cardiac index in EHPVO was 3.8 (2.3-7.7) l min(-1) m(-2), whereas it was 4.4 (2.8-8.9) l min(-1) m(-2) in cirrhosis (P = 0.468). The median (range) systemic vascular resistance index in EHPVO was 1,835 (806-3400) dyne s cm(-5) m(-2), which was similar to that in cirrhotic patients (1,800 [668-3022], P = 0.520). Similarly, the values of median (range) pulmonary vascular resistance index were comparable in the two groups (71 [42-332] vs. 79 [18-428], P = 0.885). A subgroup analysis was done for 8 patients of EHPVO and 8 age-matched compensated cirrhotic patients, which also revealed similar values of cardiac index, cardiac output, systemic vascular resistance index, systemic vascular resistance, pulmonary vascular resistance index, and pulmonary vascular resistance in the two groups. CONCLUSIONS: EHPVO patients have hyperdynamic circulation manifested by high cardiac index and low systemic and pulmonary vascular resistance indices. These hemodynamic changes are comparable with compensated cirrhotic patients who have similar grade of portal hypertension. This suggests a predominant role of portal hypertension per se in the genesis of systemic and pulmonary hemodynamic alterations.