Jonathan G Stine, Puja M Shah, Scott L Cornella, Sean R Rudnick, Marwan S Ghabril, George J Stukenborg,
Patrick G Northup
Jonathan G Stine, Sean R Rudnick, Patrick G Northup,
Division of Gastroenterology and Hepatology, University of
Virginia, Charlottesville, VA 22908, United States
Puja M Shah, Department of Surgery, University of Virginia,
Charlottesville, VA 22908, United States
Scott L Cornella, Department of Medicine, University of
Virginia, Charlottesville, VA 22908, United States
Marwan S Ghabril, Division of Gastroenterology and Hepatology,
Indiana University, Indianapolis, IN 46202, United States
George J Stukenborg, Department of Public Health Science,
University of Virginia, Charlottesville, VA 22908, United States
Author contributions: Stine JG and Shah PM contributed equally
to this work; Stine JG, Shah PM, Ghabril MS, Stukenborg GJ
and Northup PG designed research; Stine JG, Shah PM, Cornella
SL and Rudnick SR performed research; Stine JG and Shah PM
analyzed data; Stine JG, Shah PM, Cornella SL, Rudnick SR,
Ghabril MS, Stukenborg GJ and Northup PG wrote the paper.
Supported by (In part) grant funding from the National
Institutes of Health (Grant 5T32DK007769-15); and NIH-
Surgical Oncology grant (T32 CA163177).
Conflict-of-interest statement: We have no conflicts of interest
to report.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Correspondence to: Jonathan G Stine, MD, MSc, Division
of Gastroenterology and Hepatology, University of Virginia, JPA
and Lee Street, MSB 2145, PO Box 800708, Charlottesville, VA
22908, United States. [email protected]
Telephone: +1-434-9242959
Fax: +1-434-2447529
Received: September 18, 2015
Peer-review started: September 19, 2015
First decision: October 21, 2015
Revised: November 2, 2015
Accepted: November 10, 2015
Article in press: November 11, 2015
Published online: November 28, 2015
Abstract
AIM: To determine the clinical impact of portal vein
thrombosis in terms of both mortality and hepatic
decompensations (variceal hemorrhage, ascites, por-
tosystemic encephalopathy) in adult patients with
cirrhosis.
METHODS: We identified original articles reported
through February 2015 in MEDLINE, Scopus, Science
Citation Index, AMED, the Cochrane Library, and
relevant examples available in the grey literature. Two
independent reviewers screened all citations for inclu-
sion criteria and extracted summary data. Random
effects odds rati ...
Аллопуринол и прогрессирование ХБП и кардиоваскулярные события. РКИ / Allopur...hivlifeinfo
Allopurinol and Progression of CKD and Cardiovascular Events- Long-term Follow-up of a Randomized Clinical Trial.Am J Kidney Dis. 2015 Apr
Background:Asymptomatic hyperuricemia increases renal and cardiovascular (CV) risk. We previously
conducted a 2-year, single-blind, randomized, controlled trial of allopurinol treatment that showed improved
estimated glomerular filtration rate and reduced CV risk.
Study Design:Post hoc analysis of a long-term follow-up after completion of the 2-year trial.
Setting & Participants:113 participants (57 in the allopurinol group and 56 in the control group) initially
followed up for 2 years and 107 participants followed up to 5 additional years.
Intervention: Continuation of allopurinol treatment, 100 mg/d, or standard treatment.
Outcome:Renal event (defined as starting dialysis therapy and/or doubling serum creatinine and/or$50%
decrease in estimated estimated glomerular filtration rate) and CV events (defined as myocardial infarction,
coronary revascularization or angina pectoris, congestive heart failure, cerebrovascular disease, and peripheral vascular disease).
Results:During initial follow-up, there were 2 renal and 7 CV events in the allopurinol group compared with
6 renal and 15 CV events in the control group. In the long-term follow-up period, 12 of 56 participants taking
allopurinol stopped treatment and 10 of 51 control participants received allopurinol. During long-term follow-up,
an additional 7 and 9 participants in the allopurinol group experienced a renal or CV event, respectively, and an
additional 18 and 8 participants in the control group experienced a renal or CV event, respectively. Thus,
during the initial and long-term follow-up (median, 84 months), 9 patients in the allopurinol group had a
renal event compared with 24 patients in the control group (HR, 0.32; 95% CI, 0.15-0.69; P50.004;
adjusted for age, sex, baseline kidney function, uric acid level, and renin-angiotensin-aldosterone system
blockers). Overall, 16 patients treated with allopurinol experienced CV events compared with 23 in the
control group (HR, 0.43; 95% CI, 0.21-0.88;P50.02; adjusted for age, sex, and baseline kidney function).
Limitations:Small sample size, single center, not double blind, post hoc follow-up and analysis.
Conclusions: Long-term treatment with allopurinol may slow the rate of progression of kidney disease and
reduce CV risk.
This study assessed the relationship between electrocardiographic (ECG) left ventricular hypertrophy (LVH) and blood pressure (BP) control in 17,312 hypertensive patients from China. 1) 8.1% of patients had ECG-LVH, which was more prevalent in males. 2) Patients with ECG-LVH had a significantly higher rate of unsatisfactory BP control, with an odds ratio of 1.42, compared to those without ECG-LVH. 3) Notable differences in BP control were also seen between males and females and in patients with diabetes, with ECG-LVH patients having poorer control.
This summarizes a journal club discussion on a clinical trial examining the effects of allopurinol treatment in patients with chronic kidney disease (CKD). The trial found that allopurinol attenuated the decline in glomerular filtration rate compared to controls and reduced cardiovascular events and inflammatory markers. However, the study had some limitations as an open-label, single-center trial with a small sample size. While allopurinol showed potential benefits, larger and more robust studies are still needed before strongly recommending its use to attenuate CKD progression.
This randomized controlled trial compared the efficacy of pentoxifylline and prednisolone in treating severe alcoholic hepatitis. 68 patients were divided into two groups - one received pentoxifylline and the other received prednisolone for 4 weeks, followed by a tapering dose of prednisolone over 7 weeks. More patients died in the prednisolone group (12 patients) compared to the pentoxifylline group (5 patients) by 3 months. Patients receiving prednisolone also had more life-threatening complications like hepatorenal syndrome and gastrointestinal bleeding. The study suggests pentoxifylline is superior to prednisolone for treating severe alcoholic hepatitis due to its reduced mortality and renopro
This document provides a summary of the November 2014 issue of the UTSW Internal Medicine Journal Watch. It includes summaries of articles on topics such as assessing acid-base disturbances, managing Staphylococcus aureus bacteremia, community acquired pneumonia, predicting hepatocellular carcinoma in hepatitis C patients, and guidelines for prioritizing patients for new hepatitis C treatments. It also reviews articles related to infectious diseases, critical care, nephrology, cardiology, and more.
Lipid Screening in Childhood for Detection of Multifactorial DyslipidemiaGlobal Medical Cures™
Lipid Screening in Childhood for Detection of Multifactorial Dyslipidemia
IMPORTANT NOTE TO USERS OF WEBSITE & DOCUMENTS POSTED ON SLIDESHARE- Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
www.globalmedicalcures.com
This study analyzed trends in complications from 2000-2012 using a nationwide database of inpatient therapeutic ERCP procedures in the US. The study found:
1) Mortality rates decreased from 1.77% to 1.24%, and time series analysis confirmed this downward trend.
2) Perforation rates increased from 0.07% to 0.10% but time series analysis found no significant trend.
3) GI hemorrhage rates increased from 1.36% to 1.57% and time series analysis confirmed an upward trend.
The study concluded that while therapeutic ERCPs have become safer as shown by decreasing mortality rates, GI hemorrhage rates increased over the same period according to their analysis of
Аллопуринол и прогрессирование ХБП и кардиоваскулярные события. РКИ / Allopur...hivlifeinfo
Allopurinol and Progression of CKD and Cardiovascular Events- Long-term Follow-up of a Randomized Clinical Trial.Am J Kidney Dis. 2015 Apr
Background:Asymptomatic hyperuricemia increases renal and cardiovascular (CV) risk. We previously
conducted a 2-year, single-blind, randomized, controlled trial of allopurinol treatment that showed improved
estimated glomerular filtration rate and reduced CV risk.
Study Design:Post hoc analysis of a long-term follow-up after completion of the 2-year trial.
Setting & Participants:113 participants (57 in the allopurinol group and 56 in the control group) initially
followed up for 2 years and 107 participants followed up to 5 additional years.
Intervention: Continuation of allopurinol treatment, 100 mg/d, or standard treatment.
Outcome:Renal event (defined as starting dialysis therapy and/or doubling serum creatinine and/or$50%
decrease in estimated estimated glomerular filtration rate) and CV events (defined as myocardial infarction,
coronary revascularization or angina pectoris, congestive heart failure, cerebrovascular disease, and peripheral vascular disease).
Results:During initial follow-up, there were 2 renal and 7 CV events in the allopurinol group compared with
6 renal and 15 CV events in the control group. In the long-term follow-up period, 12 of 56 participants taking
allopurinol stopped treatment and 10 of 51 control participants received allopurinol. During long-term follow-up,
an additional 7 and 9 participants in the allopurinol group experienced a renal or CV event, respectively, and an
additional 18 and 8 participants in the control group experienced a renal or CV event, respectively. Thus,
during the initial and long-term follow-up (median, 84 months), 9 patients in the allopurinol group had a
renal event compared with 24 patients in the control group (HR, 0.32; 95% CI, 0.15-0.69; P50.004;
adjusted for age, sex, baseline kidney function, uric acid level, and renin-angiotensin-aldosterone system
blockers). Overall, 16 patients treated with allopurinol experienced CV events compared with 23 in the
control group (HR, 0.43; 95% CI, 0.21-0.88;P50.02; adjusted for age, sex, and baseline kidney function).
Limitations:Small sample size, single center, not double blind, post hoc follow-up and analysis.
Conclusions: Long-term treatment with allopurinol may slow the rate of progression of kidney disease and
reduce CV risk.
This study assessed the relationship between electrocardiographic (ECG) left ventricular hypertrophy (LVH) and blood pressure (BP) control in 17,312 hypertensive patients from China. 1) 8.1% of patients had ECG-LVH, which was more prevalent in males. 2) Patients with ECG-LVH had a significantly higher rate of unsatisfactory BP control, with an odds ratio of 1.42, compared to those without ECG-LVH. 3) Notable differences in BP control were also seen between males and females and in patients with diabetes, with ECG-LVH patients having poorer control.
This summarizes a journal club discussion on a clinical trial examining the effects of allopurinol treatment in patients with chronic kidney disease (CKD). The trial found that allopurinol attenuated the decline in glomerular filtration rate compared to controls and reduced cardiovascular events and inflammatory markers. However, the study had some limitations as an open-label, single-center trial with a small sample size. While allopurinol showed potential benefits, larger and more robust studies are still needed before strongly recommending its use to attenuate CKD progression.
This randomized controlled trial compared the efficacy of pentoxifylline and prednisolone in treating severe alcoholic hepatitis. 68 patients were divided into two groups - one received pentoxifylline and the other received prednisolone for 4 weeks, followed by a tapering dose of prednisolone over 7 weeks. More patients died in the prednisolone group (12 patients) compared to the pentoxifylline group (5 patients) by 3 months. Patients receiving prednisolone also had more life-threatening complications like hepatorenal syndrome and gastrointestinal bleeding. The study suggests pentoxifylline is superior to prednisolone for treating severe alcoholic hepatitis due to its reduced mortality and renopro
This document provides a summary of the November 2014 issue of the UTSW Internal Medicine Journal Watch. It includes summaries of articles on topics such as assessing acid-base disturbances, managing Staphylococcus aureus bacteremia, community acquired pneumonia, predicting hepatocellular carcinoma in hepatitis C patients, and guidelines for prioritizing patients for new hepatitis C treatments. It also reviews articles related to infectious diseases, critical care, nephrology, cardiology, and more.
Lipid Screening in Childhood for Detection of Multifactorial DyslipidemiaGlobal Medical Cures™
Lipid Screening in Childhood for Detection of Multifactorial Dyslipidemia
IMPORTANT NOTE TO USERS OF WEBSITE & DOCUMENTS POSTED ON SLIDESHARE- Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
www.globalmedicalcures.com
This study analyzed trends in complications from 2000-2012 using a nationwide database of inpatient therapeutic ERCP procedures in the US. The study found:
1) Mortality rates decreased from 1.77% to 1.24%, and time series analysis confirmed this downward trend.
2) Perforation rates increased from 0.07% to 0.10% but time series analysis found no significant trend.
3) GI hemorrhage rates increased from 1.36% to 1.57% and time series analysis confirmed an upward trend.
The study concluded that while therapeutic ERCPs have become safer as shown by decreasing mortality rates, GI hemorrhage rates increased over the same period according to their analysis of
1) A meta-analysis of 27 randomized trials found that treating anemia in chronic kidney disease patients with erythropoiesis-stimulating agents (ESAs) to achieve higher hemoglobin levels increased risks of stroke, worsening hypertension, and vascular access thrombosis compared to lower hemoglobin targets.
2) No significant differences were found between higher and lower hemoglobin targets for risks of death, cardiovascular events, or progression to kidney failure requiring dialysis.
3) While higher hemoglobin targets reduced need for blood transfusions, they increased use of intravenous iron therapy.
Hemorheological indexes, living habits, medical history and genetics factor are primary risk factors in Coronary Heart Disease (CHD). In the present study the relation of all factors to the severity of CHD was examined. The data of 282 patients (mean age: 60±9 years) diagnosed with CHD and 229 healthy controls (mean age: 59±7 years) from Wenzhou Medical University were analyzed.
Life course trajectories of systolic blood pressure using longitudinal data f...Diyan Yunanto Setyaji
This study analyzed longitudinal data on systolic blood pressure (SBP) from eight UK cohorts to describe typical SBP trajectories from childhood through late adulthood. Four distinct life course phases were observed in both sexes: a rapid rise in adolescence, a gentle increase in early adulthood, midlife acceleration beginning around age 40, and deceleration and decline in late adulthood. These patterns persisted after adjusting for body mass index, though the decline in old age was less evident when excluding individuals taking blood pressure medications. The occupational cohort had lower average SBP and shallower midlife rises compared to population cohorts. Men had higher SBP than women until ages 60-70 when this difference disappeared.
1) The study examined the relationship between time spent in two sedentary behaviors - riding in a car and watching television - and cardiovascular disease mortality in over 7,700 men over 21 years of follow up.
2) The results showed that greater time spent riding in a car and greater combined time spent in these two sedentary behaviors were both associated with higher risk of cardiovascular disease mortality.
3) Men who reported spending over 10 hours per week riding in a car or over 23 hours per week in combined sedentary behaviors had around 80% and 60% greater risk of cardiovascular disease death respectively, compared to men reporting under 4 and 11 hours per week.
4) However, higher levels of physical
Systematic literature review services | Cardiovascular research | Bariatric s...Pubrica
Pubrica provides support with medical data collection project work, Comprehensive Review Of Medical Data Collection Systems For Efficient Patient Health Care.
Visit us for high quality research services @ https://pubrica.com/services/research-services/
Contact us @ sales@pubrica.com
This meta-analysis compared the effectiveness of surgical procedures for portal hypertension, including selective or nonselective shunts, devascularization, and combined shunt and devascularization. It found that shunt procedures were more effective at reducing rebleeding compared to devascularization alone, but also carried a higher risk of encephalopathy. Combined shunt and devascularization was more effective at reducing portal vein pressure and rebleeding than devascularization alone. There were no significant differences in outcomes between selective and nonselective shunts. The analysis was based on data from randomized controlled trials involving over 1000 patients with portal hypertension.
This document summarizes guidelines from the Eighth Joint National Committee for the management of high blood pressure in adults. It recommends treating hypertensive persons aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a diastolic goal of less than 90 mm Hg. For those under 60, the recommended goal is less than 140/90 mm Hg based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or chronic kidney disease. The guidelines recommend initial drug treatment for nonblack populations with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics. For black populations, calcium channel blockers or th
The document summarizes the results of a nationwide survey in Germany that monitored treatment decisions for chronic lymphocytic leukemia (CLL) patients from 2006 to 2011. The survey found that over this period:
1) The percentage of patients diagnosed in early disease stages increased from 66% in 2006 to 77% in 2011.
2) Treatment options shifted from chlorambucil in 2006 to fludarabine-containing regimens in 2009 and the combination of rituximab and bendamustine in 2011.
3) Immune-chemotherapy treatments were administered more often, increasing from 15% of patients in 2006 to 73% in 2011.
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The degree to which stigma affects the
health-related quality of life (HRQoL) of patients with chronic
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associated with HRQoL
This study analyzed data from over 1,400 patients hospitalized for hepatorenal syndrome (HRS) in Japan between 2010-2019 using a national inpatient database. The results showed that 65.5% of patients died or underwent liver transplantation. Patients in this group had more advanced liver disease, were more likely to be male, and had higher rates of complications like hepatocellular carcinoma and spontaneous bacterial peritonitis. Over half of all patients received albumin therapy, while noradrenaline and dopamine were used as vasoconstrictors, with dopamine being more common than noradrenaline in clinical practice despite guidelines recommending noradrenaline. Mortality from HRS in Japan remains high.
This document summarizes the recommendations from an expert panel on the management of high blood pressure in adults. Key recommendations include:
1) Treating all adults aged 60 or older to a blood pressure under 150/90 mm Hg and those aged 30-59 to under 140/90 mm Hg.
2) Initial drug treatment for most nonblack adults should include a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black adults, initial treatment is a calcium channel blocker or thiazide diuretic.
3) Treatment goals are the same for adults with diabetes or nondiabetic kidney disease as the
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic). The most appropriate first
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic).
- For non
Eighth Joint National Committee (JNC 8) - Blood Pressure in AdultsSandru Acevedo MD
The panel recommends the following for treatment of hypertension in adults:
- For patients aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For patients aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For nonblack patients, including those with diabetes, initially treat with a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For black patients, including those with diabetes, initially treat with a calcium channel blocker or thiazide-type diuretic.
Jnc 8 guidelines for management of high blood pressure: Lets compare with JNC 7Dr. Afzal Haq Asif
This guideline from the Eighth Joint National Committee provides evidence-based recommendations for the management of high blood pressure in adults. There is strong evidence that treating hypertensive patients aged 60 years or older to a blood pressure goal of less than 150/90 mm Hg and those aged 30-59 years to a goal of less than 90 mm Hg improves health outcomes. For hypertensive patients under age 60, a goal of less than 140/90 mm Hg is recommended based on expert opinion due to insufficient evidence for specific systolic and diastolic goals. The guideline also recommends initiating drug treatment for hypertension with certain classes of medications, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium
The panel recommends the following for treatment of hypertension in adults:
- For ages 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For ages 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those under 30, or ages 60 or older with diabetes or kidney disease, treat to a goal of less than 140/90 mm Hg.
- Initial drug treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For nonblack populations, including those with diabetes, consider a
The panel recommends the following based on its systematic review of evidence:
1) For most adults aged 60 years or older, treat SBP to a goal of less than 150 mm Hg and DBP to a goal of less than 90 mm Hg.
2) For nonblack adults younger than 60 years, treat SBP to a goal of less than 140 mm Hg and DBP to a goal of less than 90 mm Hg.
3) Initial drug treatment should include thiazide-type diuretics, calcium channel blockers, ACE inhibitors, or ARBs.
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Systematic literature review services | Cardiovascular research | Bariatric s...Pubrica
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This meta-analysis compared the effectiveness of surgical procedures for portal hypertension, including selective or nonselective shunts, devascularization, and combined shunt and devascularization. It found that shunt procedures were more effective at reducing rebleeding compared to devascularization alone, but also carried a higher risk of encephalopathy. Combined shunt and devascularization was more effective at reducing portal vein pressure and rebleeding than devascularization alone. There were no significant differences in outcomes between selective and nonselective shunts. The analysis was based on data from randomized controlled trials involving over 1000 patients with portal hypertension.
This document summarizes guidelines from the Eighth Joint National Committee for the management of high blood pressure in adults. It recommends treating hypertensive persons aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a diastolic goal of less than 90 mm Hg. For those under 60, the recommended goal is less than 140/90 mm Hg based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or chronic kidney disease. The guidelines recommend initial drug treatment for nonblack populations with ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics. For black populations, calcium channel blockers or th
The document summarizes the results of a nationwide survey in Germany that monitored treatment decisions for chronic lymphocytic leukemia (CLL) patients from 2006 to 2011. The survey found that over this period:
1) The percentage of patients diagnosed in early disease stages increased from 66% in 2006 to 77% in 2011.
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Patient-Reported Outcomes: Does Stigma Affect the Quality of Life of Patients...semualkaira
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health-related quality of life (HRQoL) of patients with chronic
hepatitis B (CHB)-related diseases is not known. We evaluated the
HRQoL of patients with CHB-related disease and identified stigma
associated with HRQoL
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This document summarizes the recommendations from an expert panel on the management of high blood pressure in adults. Key recommendations include:
1) Treating all adults aged 60 or older to a blood pressure under 150/90 mm Hg and those aged 30-59 to under 140/90 mm Hg.
2) Initial drug treatment for most nonblack adults should include a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black adults, initial treatment is a calcium channel blocker or thiazide diuretic.
3) Treatment goals are the same for adults with diabetes or nondiabetic kidney disease as the
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic). The most appropriate first
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic).
- For non
Eighth Joint National Committee (JNC 8) - Blood Pressure in AdultsSandru Acevedo MD
The panel recommends the following for treatment of hypertension in adults:
- For patients aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For patients aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For nonblack patients, including those with diabetes, initially treat with a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For black patients, including those with diabetes, initially treat with a calcium channel blocker or thiazide-type diuretic.
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This guideline from the Eighth Joint National Committee provides evidence-based recommendations for the management of high blood pressure in adults. There is strong evidence that treating hypertensive patients aged 60 years or older to a blood pressure goal of less than 150/90 mm Hg and those aged 30-59 years to a goal of less than 90 mm Hg improves health outcomes. For hypertensive patients under age 60, a goal of less than 140/90 mm Hg is recommended based on expert opinion due to insufficient evidence for specific systolic and diastolic goals. The guideline also recommends initiating drug treatment for hypertension with certain classes of medications, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium
The panel recommends the following for treatment of hypertension in adults:
- For ages 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For ages 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those under 30, or ages 60 or older with diabetes or kidney disease, treat to a goal of less than 140/90 mm Hg.
- Initial drug treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For nonblack populations, including those with diabetes, consider a
The panel recommends the following based on its systematic review of evidence:
1) For most adults aged 60 years or older, treat SBP to a goal of less than 150 mm Hg and DBP to a goal of less than 90 mm Hg.
2) For nonblack adults younger than 60 years, treat SBP to a goal of less than 140 mm Hg and DBP to a goal of less than 90 mm Hg.
3) Initial drug treatment should include thiazide-type diuretics, calcium channel blockers, ACE inhibitors, or ARBs.
This study analyzed clinical outcomes of treated and untreated patients with hepatitis C virus (HCV) infection in two cohorts. It found that HCV patients who did not respond to interferon-alpha based treatment had a significantly increased risk of developing cirrhosis compared to untreated patients, even after adjusting for factors like fibrosis stage and psychosocial risks. Specifically, treatment nonresponders had a 2.35 times higher hazard of cirrhosis in the Veterans Affairs cohort and a 5.9 times higher hazard in the University Hospital cohort compared to untreated patients. However, the overall survival of nonresponders was not significantly different than untreated patients. This suggests that while interferon-alpha treatment failure may accelerate liver fibrosis, it does not necessarily impact overall
Similar to Jonathan G Stine, Puja M Shah, Scott L Cornella, Sean R Rudnic.docx (20)
The document discusses planning for material and resource requirements in operations management. It describes the relationships between forecasting, aggregate planning, master scheduling, MRP, and capacity planning. A case study is provided on how a toy company develops its aggregate production plan and master production schedule to meet demand forecasts while maintaining consistent production levels and workforce. The master schedule is adjusted as actual customer orders are received to ensure demand can be met from current inventory and production levels.
a 12 page paper on how individuals of color would be a more dominant.docxpriestmanmable
a 12 page paper on how individuals of color would be a more dominant number if they had more resources and discrimination of color was ceased. Must include those who discriminate against skin color and must include facts from sources that help individuals gain insight on the possibility of colored individuals thriving in society if same resourcesAnd equal opportunity was provided.
.
92 Academic Journal Article Critique Help with Journal Ar.docxpriestmanmable
92 Academic Journal Article Critique
Help with Journal Article Critique Assignment
Ensure the structure of the assignment will include the following:
Title Page
Introduction
Description of the Problem or Issue
Analysis
Discussion
Critique
Conclusion
References
.
A ) Society perspective90 year old female, Mrs. Ruth, from h.docxpriestmanmable
A ) Society perspective
90 year old female, Mrs. Ruth, from home with her daughter, is admitted to hospital after sustaining a hip fracture. She has a history of chronic obstructive pulmonary disease on home oxygen and moderate to severe aortic stenosis. (Obstruction of blood flow through part of the heart) She undergoes urgent hemiarthroplasty (hip surgery) with an uneventful operative course.
The patient and her family are of Jewish background. The patient’s daughter is her primary caregiver and has financial power-of-attorney, but it is not known whether she has formal power of attorney for personal care. Concerns have been raised to the ICU team about the possibility of elder abuse in the home by the patient’s daughter.
Unfortunately, on postoperative day 4, the patient develops delirium with respiratory failure secondary to hospital acquired pneumonia and pulmonary edema. (Fluid in the lungs) Her goals of care were not assessed pre-operatively. She is admitted to the ICU for non-invasive positive pressure ventilation for 48 hours, and then deteriorates and is intubated. After 48 hours of ventilation, it was determined that due to the severity of her underlying cardio-pulmonary status (COPD and aortic stenosis), ventilator weaning would be difficult and further ventilation would be futile.
The patient’s daughter is insistent on continuing all forms of life support, including mechanical ventilation and even extracorporeal membranous oxygenation (does the work of the lungs) if indicated. However, the Mrs Ruth’s delirium clears within the next 24 hours of intubation, and she is now competent, although still mechanically ventilated. She communicated to the ICU team that she preferred 1-way extubation (removal of the ventilator) and comfort care. This was communicated in writing to the ICU team, and was consistent over time with other care providers. The patient went as far to demand the extubation over the next hour, which was felt to be reasonable by the ICU team.
The patient’s daughter was informed of this decision, and stated that she could not come to the hospital for 2 hours, and in the meantime, that the patient must remain intubated.
At this point, the ICU team concurred with the patient’s wishes, and extubated her before her daughter was able to come to the hospital.
The daughter was angry at the team’s decision, and requested that the patient be re-intubated if she deteriorated. When the daughter arrived at the hospital, the patient and daughter were able to converse, and the patient then agreed to re-intubation if she deteriorated.
(1) What are the ethical issues emerging in this case? State why? (
KRISTINA)
(2) What decision model(s) would be ideal for application in this case? State your justification.
(Lacey Powell
)
(3) Who should make decisions in this situation? Should the ICU team have extubated the patient?
State if additional information was necessary for you to arrive at a better decision(s) in your case.
9 dissuasion question Bartol, C. R., & Bartol, A. M. (2017)..docxpriestmanmable
9 dissuasion question
Bartol, C. R., & Bartol, A. M. (2017). Criminal behavior: A psychological approach (11th ed.). Boston, MA: Pearson.
Chapter 12, “Sexual Assault” (pp. 348–375)
Chapter 13, “Sexual Abuse of Children and Youth” (pp. 376–402)
To prepare for this Discussion:
Review the Learning Resources.
Think about the following two statements:
Rape is seen as a pseudosexual act.
Rape is always and foremost an aggressive act.
Consider the two statements above regarding motivation of sexual assault. Is rape classified as a pseudosexual act to you, or is it more or less than that? Explain your stance. Do you see rape as an aggressive act by nature, or can it be considered otherwise in certain situations? Explain your reasoning for this.
Excellent - above expectations
Main Discussion Posting Content
Points Range:
21.6 (54%) - 24 (60%)
Discussion posting demonstrates an
excellent
understanding of
all
of the concepts and key points presented in the text/s and Learning Resources. Posting provides significant detail including multiple relevant examples, evidence from the readings and other scholarly sources, and discerning ideas.
Points Range:
19.2 (48%) - 21.57 (53.92%)
Discussion posting demonstrates a
good
understanding of
most
of the concepts and key points presented in the text/s and Learning Resources. Posting provides moderate detail (including at least one pertinent example), evidence from the readings and other scholarly sources, and discerning ideas.
Points Range:
16.8 (42%) - 19.17 (47.93%)
Discussion posting demonstrates a
fair
understanding of the concepts and key points as presented in the text/s and Learning Resources. Posting may be
lacking
or incorrect in some area, or in detail and specificity, and/or may not include sufficient pertinent examples or provide sufficient evidence from the readings.
Points Range:
0 (0%) - 16.77 (41.93%)
Discussion posting demonstrates
poor or no
understanding of the concepts and key points of the text/s and Learning Resources. Posting is incorrect and/or shallow and/or does not include any pertinent examples or provide sufficient evidence from the readings.
Reply Post & Peer Interaction
Points Range:
7.2 (18%) - 8 (20%)
Student interacts
frequently
with peers. The feedback postings and responses to questions are excellent and fully contribute to the quality of interaction by offering constructive critique, suggestions, in-depth questions, use of scholarly, empirical resources, and stimulating thoughts and/or probes.
Points Range:
6.4 (16%) - 7.16 (17.9%)
Student interacts
moderately
with peers. The feedback postings and responses to questions are good, but may not fully contribute to the quality of interaction by offering constructive critique, suggestions, in-depth questions, use of scholarly, empirical resources, and stimulating thoughts and/or probes.
Points Range:
5.6 (14%) - 6.36 (15.9%)
Student interacts
minimally
with peers .
9 AssignmentAssignment Typologies of Sexual AssaultsT.docxpriestmanmable
9 Assignment
Assignment: Typologies of Sexual Assaults
There are many different types of sexual assaults and many different types of offenders. Although they are different, they can be classified in order to create a common language between the criminal justice field and the mental health field. This in turn will enable more accurate research, predict future offenses, and assist in the prosecution and rehabilitation of the offenders.
In this Assignment, you compare different typologies of sexual offenders to determine the differences in motivation, expression of aggression, and underlining personality structure. You also determine the best way to interview each typology of sexual offenders.
To prepare for this Assignment:
Review the Learning Resources.
Select two typologies of sexual offenders listed in the resources.
By Day 7
In a 3- to 5- page paper:
Compare the two typologies of sexual offenders you selected by explaining the following:
The motivational differences between the two typologies
The expression of aggression in the two typologies
The differences in the underlining personality structure of the two typologies
Excellent - above expectations
Points Range:
47.25 (63%) - 52.5 (70%)
Paper demonstrates an
excellent
understanding of
all
of the concepts and key points presented in the text/s and Learning Resources. Paper provides significant detail including multiple relevant examples, evidence from the readings and other sources, and discerning ideas.
Points Range:
42 (56%) - 47.2 (62.93%)
Paper demonstrates a
good
understanding of
most
of the concepts and key points presented in the text/s and Learning Resources. Paper includes moderate detail, evidence from the readings, and discerning ideas.
Points Range:
36.75 (49%) - 41.95 (55.93%)
Paper demonstrates a
fair
understanding of the concepts and key points as presented in the text/s and Learning Resources. Paper may be
lacking
in detail and specificity and/or may not include sufficient pertinent examples or provide sufficient evidence from the readings.
Points Range:
0 (0%) - 36.7 (48.93%)
Paper demonstrates poor understanding of the concepts and key points of the text/s and Learning Resources. Paper is missing detail and specificity and/or does not include any pertinent examples or provide sufficient evidence from the readings.
Writing
Points Range:
20.25 (27%) - 22.5 (30%)
Paper is
well
organized, uses scholarly tone, follows APA style, uses original writing and proper paraphrasing, contains very few or no writing and/or spelling errors, and is
fully
consistent with graduate level writing style. Paper contains
multiple
, appropriate and exemplary sources expected/required for the assignment.
.
The document discusses a new guidance published by Public Health England to enhance the public health role of nurses and midwives. It aims to make every contact with patients by nurses and midwives count towards health promotion and disease prevention. The guidance prioritizes areas like reducing preventable deaths, tackling long-term conditions, and improving children's health. It also emphasizes place-based public health approaches. The document outlines specific actions nurses and midwives can take to contribute to public health at the individual, community and population levels, such as providing health advice to patients and engaging with communities.
9 Augustine Confessions (selections) Augustine of Hi.docxpriestmanmable
9 Augustine
Confessions
(selections)
Augustine of Hippo wrote his Confessions between 397 -400 CE. In it he gives an
autobiographical account of his whole life up through his conversion to Christianity.
In Book 2, excerpted here, he thinks over the passions and temptations of his youth,
especially during a period where he had to come home from where he was studying
and return to living with his parents. His mother Monica was already Christian and
his father was considering it. They want him to be academically successful and
become a great orator.
From Augustine, Confessions. Translated by Caroline J-B Hammond. Loeb Classical
Library Harvard University Press 2014
(Links to an external site.)
.
1. (1) I wish to put on record the disgusting deeds in which I engaged, and
the corrupting effect of sensual experience on my soul, not because I love
them, but so that I may love you, my God. I do this because of my love for
your love, to the end that—as I recall my wicked, wicked ways in the
bitterness of recollection—you may grow even sweeter to me. For you are
a sweetness which does not deceive, a sweetness which brings happiness
and peace, pulling me back together from the disintegration in which I was
being shattered and torn apart, when I turned away from you who are unity
https://www-loebclassics-com.offcampus.lib.washington.edu/view/augustine-confessions/2014/pb_LCL026.61.xml
https://www-loebclassics-com.offcampus.lib.washington.edu/view/augustine-confessions/2014/pb_LCL026.61.xml
https://www-loebclassics-com.offcampus.lib.washington.edu/view/augustine-confessions/2014/pb_LCL026.61.xml
https://www-loebclassics-com.offcampus.lib.washington.edu/view/augustine-confessions/2014/pb_LCL026.61.xml
https://www-loebclassics-com.offcampus.lib.washington.edu/view/augustine-confessions/2014/pb_LCL026.61.xml
and dispersed into the multiplicity that is oblivion. For there was a time
during my adolescence when I burned to have my fill of hell. I ran wild and
reckless in all manner of shady liaisons, and my outward appearance
deteriorated, and I degenerated before your eyes as I went on pleasing
myself and desiring to appear pleasing in human sight.
2. (2) What was it that used to delight me, if not loving and being loved? But
there was no boundary maintained between one mind and another, and
reaching only as far as the clear confines of friendship. Instead the slime
of fleshly desire and the spurts of adolescence belched out their fumes,
and these clouded and obscured my heart, so that it was impossible to
distinguish the purity of love from the darkness of lust. Both of them
together seethed in me, dragging my immaturity over the heights of bodily
desire, and plunging me down into a whirlpool of sin. Your anger grew
strong against me, but I was unaware of it. I had been deafened by the
loud grinding of the chain of my mortality, the punishment for the pride of
my soul, and I went even further away from yo.
8.3 Intercultural Communication
Learning Objectives
1. Define intercultural communication.
2. List and summarize the six dialectics of intercultural communication.
3. Discuss how intercultural communication affects interpersonal relationships.
It is through intercultural communication that we come to create, understand, and transform culture and identity. Intercultural communication is communication between people with differing cultural identities. One reason we should study intercultural communication is to foster greater self-awareness (Martin & Nakayama, 2010). Our thought process regarding culture is often “other focused,” meaning that the culture of the other person or group is what stands out in our perception. However, the old adage “know thyself” is appropriate, as we become more aware of our own culture by better understanding other cultures and perspectives. Intercultural communication can allow us to step outside of our comfortable, usual frame of reference and see our culture through a different lens. Additionally, as we become more self-aware, we may also become more ethical communicators as we challenge our ethnocentrism, or our tendency to view our own culture as superior to other cultures.
As was noted earlier, difference matters, and studying intercultural communication can help us better negotiate our changing world. Changing economies and technologies intersect with culture in meaningful ways (Martin & Nakayama). As was noted earlier, technology has created for some a global village where vast distances are now much shorter due to new technology that make travel and communication more accessible and convenient (McLuhan, 1967). However, as the following “Getting Plugged In” box indicates, there is also a digital divide, which refers to the unequal access to technology and related skills that exists in much of the world. People in most fields will be more successful if they are prepared to work in a globalized world. Obviously, the global market sets up the need to have intercultural competence for employees who travel between locations of a multinational corporation. Perhaps less obvious may be the need for teachers to work with students who do not speak English as their first language and for police officers, lawyers, managers, and medical personnel to be able to work with people who have various cultural identities.
“Getting Plugged In”
The Digital Divide
Many people who are now college age struggle to imagine a time without cell phones and the Internet. As “digital natives” it is probably also surprising to realize the number of people who do not have access to certain technologies. The digital divide was a term that initially referred to gaps in access to computers. The term expanded to include access to the Internet since it exploded onto the technology scene and is now connected to virtually all computing (van Deursen & van Dijk, 2010). Approximately two billion people around the world now access the Internet regularl.
8413 906 AMLife in a Toxic Country - NYTimes.comPage 1 .docxpriestmanmable
8/4/13 9:06 AMLife in a Toxic Country - NYTimes.com
Page 1 of 4http://www.nytimes.com/2013/08/04/sunday-review/life-in-a-toxic-country.html?ref=world&pagewanted=all&pagewanted=print
August 3, 2013
Life in a Toxic Country
By EDWARD WONG
BEIJING — I RECENTLY found myself hauling a bag filled with 12 boxes of milk powder and a
cardboard container with two sets of air filters through San Francisco International Airport. I was
heading to my home in Beijing at the end of a work trip, bringing back what have become two of
the most sought-after items among parents here, and which were desperately needed in my own
household.
China is the world’s second largest economy, but the enormous costs of its growth are becoming
apparent. Residents of its boom cities and a growing number of rural regions question the safety of
the air they breathe, the water they drink and the food they eat. It is as if they were living in the
Chinese equivalent of the Chernobyl or Fukushima nuclear disaster areas.
Before this assignment, I spent three and a half years reporting in Iraq, where foreign
correspondents talked endlessly of the variety of ways in which one could die — car bombs,
firefights, being abducted and then beheaded. I survived those threats, only now to find myself
wondering: Is China doing irreparable harm to me and my family?
The environmental hazards here are legion, and the consequences might not manifest themselves
for years or even decades. The risks are magnified for young children. Expatriate workers
confronted with the decision of whether to live in Beijing weigh these factors, perhaps more than at
any time in recent decades. But for now, a correspondent’s job in China is still rewarding, and so I
am toughing it out a while longer. So is my wife, Tini, who has worked for more than a dozen years
as a journalist in Asia and has studied Chinese. That means we are subjecting our 9-month-old
daughter to the same risks that are striking fear into residents of cities across northern China, and
grappling with the guilt of doing so.
Like them, we take precautions. Here in Beijing, high-tech air purifiers are as coveted as luxury
sedans. Soon after I was posted to Beijing, in 2008, I set up a couple of European-made air
purifiers used by previous correspondents. In early April, I took out one of the filters for the first
time to check it: the layer of dust was as thick as moss on a forest floor. It nauseated me. I ordered
two new sets of filters to be picked up in San Francisco; those products are much cheaper in the
United States. My colleague Amy told me that during the Lunar New Year in February, a family
http://topics.nytimes.com/top/reference/timestopics/people/w/edward_wong/index.html
http://topics.nytimes.com/top/news/international/countriesandterritories/china/index.html?inline=nyt-geo
8/4/13 9:06 AMLife in a Toxic Country - NYTimes.com
Page 2 of 4http://www.nytimes.com/2013/08/04/sunday-review/life-in-a-toxic-country..
8. A 2 x 2 Experimental Design - Quality and Economy (x1 and x2.docxpriestmanmable
8. A 2 x 2 Experimental Design: - Quality and Economy (x1 and x2 as independent variables)
Dr. Boonghee Yoo
[email protected]
RMI Distinguished Professor in Business and
Professor of Marketing & International Business
Make changes on the names, labels, and measure on the variable view.
Check the measure.
Have the same keys between “Name” and “Label.”
Run factor analysis for ys (dependent variables).
Select “Principal axis factoring” from “Extraction.”
The two-factor solution seems the best as (1) they are over one eigenvalue each and (2) the variance explained for is over 60%.
The new eigenvalues after the rotation.
The rotated factor matrix is clear.
But note that y3 and y1 are collapsed into one factor.
If not you should rerun factor analysis after removing the most problematic item one at a time.
Repeat this procedure until the rotated factor pattern has
(1) no cross-loading,
(2) no weak factor loading (< 0.5), and
(3) an adequate number of items (not more than 5 items per factor).
If a clear factor pattern is obtained, name the factors.
Attitude and purchase intention (y3 and y1)
Boycotting intention (y2)
Compute the reliability of the items of each factor
Make sure all responses were used.
Cronbach’s a (= Reliability a) must be greater than 0.70. Then, you can create the composite variable out of the member items.
Means and STDs must be similar among the items.
No a here should be greater than Cronbach’s a. If not, you should delete such item(s) to increase a.
Create the composite variable for each factor.
BI = mean (y2_1,y2_2,y2_3)
“PI” will be added to the data.
Go to the Variable View and change its “Name” and “Label.”
8. A 2 x 2 Experimental Design: - Quality and Economy (x1 and x2 as independent variables)
Dr. Boonghee Yoo
[email protected]
RMI Distinguished Professor in Business and
Professor of Marketing & International Business
BLOCK 1. Title and introductory paragraph.
Title and introductory paragraph
Plus, background questions
BLOCK 2 to 5. Show one of four treatments randomly.
x1(hi), x2 (hi)
x1 (hi), x2 (low)
x1 (low), x2 (hi)
x1 (low), x2 (low)
BLOCK 6. Questions.
Manipulation check questions (multi-item scales)
y1, y2, and y3 (multi-item scales)
Socio-demographic questions
Write “Thank you for participation.”
The questionnaire (6 blocks)
A 2x2 between-sample design: SQ (Service quality and ECON (Contribution to local economy)
Each of the four BLOCKs consist of:
The instruction: e.g., “Please read the following description of company ABC carefully.”
The scenario: An image file or written statement
(No questions inside the scenario blocks)
Qualtrics Survey Flow (6 blocks)
Manipulation check questions y1, y2, …, yn
Questions to verify that subjects were manipulated as intended. For example, if the stimulus is dollar-amount price, the manipulation check.
800 Words 42-year-old man presents to ED with 2-day history .docxpriestmanmable
800 Words
42-year-old man presents to ED with 2-day history of dysuria, low back pain, inability to fully empty his bladder, severe perineal pain along with fevers and chills. He says the pain is worse when he stands up and is somewhat relieved when he lies down. Vital signs T 104.0 F, pulse 138, respirations 24. PaO2 96% on room air. Digital rectal exam (DRE) reveals the prostate to be enlarged, extremely tender, swollen, and warm to touch.
In your Case Study Analysis related to the scenario provided, explain the following:
The factors that affect fertility (STDs).
Why inflammatory markers rise in STD/PID.
Why prostatitis and infection happen. Also explain the causes of systemic reaction.
Why a patient would need a splenectomy after a diagnosis of ITP.
Anemia and the different kinds of anemia (i.e., micro, and macrocytic).
.
8.1 What Is Corporate StrategyLO 8-1Define corporate strategy.docxpriestmanmable
8.1 What Is Corporate Strategy?
LO 8-1
Define corporate strategy and describe the three dimensions along which it is assessed.
Strategy formulation centers around the key questions of where and how to compete. Business strategy concerns the question of how to compete in a single product market. As discussed in Chapter 6, the two generic business strategies that firms can follow to pursue their quest for competitive advantage are to increase differentiation (while containing cost) or lower costs (while maintaining differentiation). If trade-offs can be reconciled, some firms might be able to pursue a blue ocean strategy by increasing differentiation and lowering costs. As firms grow, they are frequently expanding their business activities through seeking new markets both by offering new products and services and by competing in different geographies. Strategic leaders must formulate a corporate strategy to guide continued growth. To gain and sustain competitive advantage, therefore, any corporate strategy must align with and strengthen a firm’s business strategy, whether it is a differentiation, cost-leadership, or blue ocean strategy.
Corporate strategy comprises the decisions that leaders make and the goal-directed actions they take in the quest for competitive advantage in several industries and markets simultaneously.3 It provides answers to the key question of where to compete. Corporate strategy determines the boundaries of the firm along three dimensions: vertical integration along the industry value chain, diversification of products and services, and geographic scope (regional, national, or global markets). Strategic leaders must determine corporate strategy along the three dimensions:
1. Vertical integration: In what stages of the industry value chain should the company participate? The industry value chain describes the transformation of raw materials into finished goods and services along distinct vertical stages.
2. Diversification: What range of products and services should the company offer?
3. Geographic scope: Where should the company compete geographically in terms of regional, national, or international markets?
In most cases, underlying these three questions is an implicit desire for growth. The need for growth is sometimes taken so much for granted that not every manager understands all the reasons behind it. A clear understanding will help strategic leaders to pursue growth for the right reasons and make better decisions for the firm and its stakeholders.
WHY FIRMS NEED TO GROW
LO 8-2
Explain why firms need to grow, and evaluate different growth motives.
Several reasons explain why firms need to grow. These can be summarized as follows:
1. Increase profits.
2. Lower costs.
3. Increase market power.
4. Reduce risk.
5. Motivate management.
Let’s look at each reason in turn.
INCREASE PROFITS
Profitable growth allows businesses to provide a higher return for their shareholders, or owners, if privately held. For publicly trade.
8.0 RESEARCH METHODS These guidelines address postgr.docxpriestmanmable
8.0 RESEARCH METHODS
These guidelines address postgraduate students who have completed course
requirements and assumed to have sufficient background experience of high-level
engagement activities like recognizing, relating, applying, generating, reflecting and
theorizing issues. It is an ultimate period in our academic life when we feel confident
at embarking on independent research.
It cannot be overemphasized that we must enjoy the experience of research process
and not look at it as an academic chore.
To enable such a desired behaviour, these guidelines consider the research process
in terms of the skills and knowledge needed to develop independent and critical
styles of thinking in order to evaluate and use research as well as to conduct fresh
research.
The guidelines should be viewed as briefs which the Research Supervisors are expected
to exemplify based on their own experience as well as expertise.
8.1 Chapter 1 - Introduction
INTRODUCE the subject or problem to be studied. This might require the
identification of key managerial concerns, theories, laws and governmental rulings,
critical incidents or social changes, and current environmental issues, that make the
subject critical, relevant and worthy of managerial or research attention.
• To inform the Reader (stylistically - forthright, direct, and brief / concise),
• The first sentence should begin with `This Study was intended
to’….’ And immediately tell the Reader the nature of the study for the
reader's interest and desire to read on.
8.1.1 The Research Problem
What is the statement of the problem? The statement of the problem or problem
statement should follow logically from what has been set forth in the background of
the problem by defining the specific research need providing impetus for the
study, a need not met through previous research. Present a clear and precise
statement of the central question of research, formulated to address the need.
8.1.2 The Purpose of the Study
What is the purpose of the study? What are the RESEARCH QUESTION (S) of
the study? What are the specific objective (s) of the study? Define the specific
research objective (s) that would answer the research Question (s) of the study.
8.1.3 The Rationale of the Study:
1. Why in a general sense?
2. One or two brief references to previous research or theories critical in structuring
this study to support and understand the rationale.
3. The importance of the study for the reader to know, to fully appreciate the need
for the study - and its significance.
4. Own professional experience that stimulated the study or aroused interest in the
area of research.
5. The Need for the Study - will deal with valid questions or professional concerns
to provide data leading to an answer - reference to literature helpful and
appropriate.
8.1.4 The Significance of the Study:
1. Clearly .
95People of AppalachianHeritageChapter 5KATHLEEN.docxpriestmanmable
95
People of Appalachian
Heritage
Chapter 5
KATHLEEN W. HUTTLINGER and LARRY D. PURNELL
Overview, Inhabited Localities,
and Topography
OVERVIEW
Appalachia consists of that large geographic expanse in
the eastern United States that is associated with the
Appalachian mountain system, a 200,000-square-mile
region that extends from the northeastern United States
in southern New York to northern Mississippi. It includes
all of West Virginia and parts of Alabama, Georgia,
Kentucky, Maryland, Mississippi, New York, North
Carolina, Ohio, Pennsylvania, South Carolina, Tennessee,
and Virginia. This very rural area is characterized by a
rolling topography with very rugged ridges and hilltops,
some extending over 4000 feet high, with remote valleys
between them. The surrounding valleys are often 2000
feet or more in elevation and give one a sense of isolation,
peacefulness, and separateness from the lower and more
heavily traveled urban areas. This isolation and rough
topography have contributed to the development of
secluded communities in the hills and natural hollows or
narrow valleys where people, over time, have developed a
strong sense of independence and family cohesiveness.
These same isolated valleys and rugged mountains pre-
sent many transportation problems for those who do not
have access to cars or trucks. Very limited public trans-
portation is available only in the larger urbanized areas.
Even though the Appalachian region includes several
large cities, many people live in small settlements and in
inaccessible hollows or “hollers” (Huttlinger, Schaller-
Ayers, & Lawson, 2004a). The rugged location of many
communities in Appalachia results in a population that is
often isolated from the mainstream of health-care ser-
vices. In some areas of Appalachia, substandard secondary
and tertiary roads, as well as limited public bus, rail, and
airport facilities, prevent easy access to the area (Fig. 5–1).
Difficulty in accessing the area is partially responsible for
continued geographic and sociocultural isolation. The
rugged terrain can significantly delay ambulance response
time and is a deterrent to people who need health care
when their health condition is severe. This is one area in
which telehealth innovations can and often do provide
needed services.
Many of the approximately 24 million people who live
in Appalachia can trace their family roots back 150 or
more years, and it is common to find whole communities
comprising extended, related families. The cultural her-
itage of the region is rich and reflected in their distinctive
music, art, and literature. Even though family roots are
strong, many of the region’s younger residents have left
the area to pursue job opportunities in the larger urban
cities of the north. The remaining, older population
reflects a group that often has less than a high-school edu-
cation, is frequently unemployed, may be on welfare
and/or disability, and is regularly uninsured (20.4 per-
cent) (Virginia He.
8-10 slide Powerpoint The example company is Tesla.Instructions.docxpriestmanmable
8-10 slide Powerpoint The example company is Tesla.
Instructions
As the organization’s top leader, you are responsible for communicating the organization’s strategies in a way that makes the employees understand the role that they play in helping to achieve the organization’s strategies. Design a presentation that explains the following:
The company is Tesla
1. Your Organization's Mission and Vision
2. Your organization’s overall strategies and how they align with the Mission and Vision
3. At least five of your organization’ strategic SMART goals that align with the overall organizational strategy
4. At least three different departments’ specific roles in helping to achieve those strategic SMART goals
5. This can be a PowerPoint presentation with a voice-over or it can be a video presentation.
Length: 8 – 10 slides, not including title and reference slide.
Notes Length: 200-250 words for each slide.
References: Include a minimum of five scholarly resources.
I will do the voice over. I do not need a separate document of speaker notes as long as the PowerPoint has the requested 200-250 words for each slide
.
8Network Security April 2020FEATUREAre your IT staf.docxpriestmanmable
8
Network Security April 2020
FEATURE
Are your IT staff ready
for the pandemic-driven
insider threat? Phil Chapman
Obviously the threat to human life is
the top concern for everyone at this
moment. But businesses are also starting
to suffer as productivity slips globally
and the workforce itself is squeezed.
The UK Government’s March budget
did announce some measures, especially
for small and medium-size enterprises
(SMEs), that will make this period
slightly less painful for organisations.
However, as is apparent from the tank-
ing stock market (the FTSE 100 has
hit levels not seen since June 2012) the
economy and pretty much all businesses
in the country (unless you produce hand
sanitiser) are going to suffer. There is no
time like now for the UK to embrace
its mantra of ‘keep calm and carry on’
because that is what we must do if we’re
going to keep business flowing.
For the IT department at large there is
lots of urgent work to do to ensure that
the business is prepared to keep running
smoothly even if people are having to
work remotely. The task at hand for cyber
security professionals is arguably even
larger as Covid-19 is seeing cyber criminals
capitalising on the fact that the insider
threat is worse than ever, with more people
working remotely from personal devices
than many IT and cyber security teams
have likely ever prepared for.
This article will argue that the cyber
security workforce, which is already suf-
fering a digital skills crisis, may also be
lacking the adequate soft skills required
to effectively tackle the insider threat
that has been exacerbated by the pan-
demic. It will first examine the insider
threat, and why this has become so
much more insidious because of Covid-
19. It will then look into the essential
soft skills required to tackle this threat,
before examining how organisations can
effectively implement an apprentice-
ship strategy that generates professionals
with both hard and soft skills, includ-
ing advice from the CISO of globally
respected law firm Pinsent Masons, who
will provide insight into how he is mak-
ing his strategy work. It will conclude
that many of these issues could be solved
if the industry didn’t rely so heavily on
recruiting graduates and rather looked
towards hiring apprentices.
The insider threat
In the best of times, every cyber-pro-
fessional knows that the biggest threat
to an organisation’s IT infrastructure
is people, both malicious actors and
– much more often – employees and
partners making mistakes. The problem
is that people lack cyber knowledge and
so commit careless actions – for exam-
ple, forwarding sensitive information to
the wrong recipient over email or plug-
ging rogue USBs into their device (yes,
that still happens). Cyber criminals
capitalise on this ignorance by utilising
social engineering tactics ranging from
the painfully simple, like fake emails
from Amazon, to the very sophisticated,
such as.
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
How to Make a Field Mandatory in Odoo 17Celine George
In Odoo, making a field required can be done through both Python code and XML views. When you set the required attribute to True in Python code, it makes the field required across all views where it's used. Conversely, when you set the required attribute in XML views, it makes the field required only in the context of that particular view.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
Jonathan G Stine, Puja M Shah, Scott L Cornella, Sean R Rudnic.docx
1. Jonathan G Stine, Puja M Shah, Scott L Cornella, Sean R
Rudnick, Marwan S Ghabril, George J Stukenborg,
Patrick G Northup
Jonathan G Stine, Sean R Rudnick, Patrick G Northup,
Division of Gastroenterology and Hepatology, University of
Virginia, Charlottesville, VA 22908, United States
Puja M Shah, Department of Surgery, University of Virginia,
Charlottesville, VA 22908, United States
Scott L Cornella, Department of Medicine, University of
Virginia, Charlottesville, VA 22908, United States
Marwan S Ghabril, Division of Gastroenterology and
Hepatology,
Indiana University, Indianapolis, IN 46202, United States
George J Stukenborg, Department of Public Health Science,
University of Virginia, Charlottesville, VA 22908, United
States
Author contributions: Stine JG and Shah PM contributed equally
to this work; Stine JG, Shah PM, Ghabril MS, Stukenborg GJ
and Northup PG designed research; Stine JG, Shah PM,
Cornella
SL and Rudnick SR performed research; Stine JG and Shah PM
analyzed data; Stine JG, Shah PM, Cornella SL, Rudnick SR,
Ghabril MS, Stukenborg GJ and Northup PG wrote the paper.
Supported by (In part) grant funding from the National
Institutes of Health (Grant 5T32DK007769-15); and NIH-
2. Surgical Oncology grant (T32 CA163177).
Conflict-of-interest statement: We have no conflicts of interest
to report.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was
selected by an in-house editor and fully peer-reviewed by
external
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0)
license,
which permits others to distribute, remix, adapt, build upon this
work non-commercially, and license their derivative works on
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
Correspondence to: Jonathan G Stine, MD, MSc, Division
of Gastroenterology and Hepatology, University of Virginia,
JPA
and Lee Street, MSB 2145, PO Box 800708, Charlottesville, VA
22908, United States. [email protected]
Telephone: +1-434-9242959
Fax: +1-434-2447529
Received: September 18, 2015
Peer-review started: September 19, 2015
First decision: October 21, 2015
Revised: November 2, 2015
Accepted: November 10, 2015
Article in press: November 11, 2015
Published online: November 28, 2015
3. Abstract
AIM: To determine the clinical impact of portal vein
thrombosis in terms of both mortality and hepatic
decompensations (variceal hemorrhage, ascites, por-
tosystemic encephalopathy) in adult patients with
cirrhosis.
METHODS: We identified original articles reported
through February 2015 in MEDLINE, Scopus, Science
Citation Index, AMED, the Cochrane Library, and
relevant examples available in the grey literature. Two
independent reviewers screened all citations for inclu-
sion criteria and extracted summary data. Random
effects odds ratios were calculated to obtain aggregate
estimates of effect size across included studies, with
95%CI.
RESULTS: A total of 226 citations were identified
and reviewed, and 3 studies with 2436 participants
were included in the meta-analysis of summary effect.
Patients with portal vein thrombosis had an increased
risk of mortality (OR = 1.62, 95%CI: 1.11-2.36, P =
0.01). Portal vein thrombosis was associated with an
increased risk of ascites (OR = 2.52, 95%CI: 1.63-3.89,
P < 0.001). There was insufficient data available
to determine the pooled effect on other markers of
META-ANALYSIS
Submit a Manuscript: http://www.wjgnet.com/esps/
Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx
DOI: 10.4254/wjh.v7.i27.2774
2774 November 28, 2015|Volume 7|Issue
27|WJH|www.wjgnet.com
5. number of included studies limits more generalizable
conclusions. More trials with a direct comparison group
are needed.
Stine JG, Shah PM, Cornella SL, Rudnick SR, Ghabril MS,
Stukenborg GJ, Northup PG. Portal vein thrombosis, mortality
and hepatic decompensation in patients with cirrhosis: A meta-
analysis. World J Hepatol 2015; 7(27): 2774-2780 Available
from: URL: http://www.wjgnet.com/1948-
5182/full/v7/i27/2774.
htm DOI: http://dx.doi.org/10.4254/wjh.v7.i27.2774
INTRODUCTION
Portal vein thrombosis (PVT) is defined as an obstruction
of the portal vein or its branches, which include the
splenic, superior mesenteric, and inferior mesenteric
veins[1]. It is associated with numerous conditions
including malignancy, myeloproliferative disorders,
inflammatory conditions (such as pancreatitis), intra-
abdominal infections (such as secondary peritonitis), and
cirrhosis[2,3]. PVT is common in patients with cirrhosis;
over 30% of liver transplant recipients have PVT on direct
explant examination at the time of transplant (LT)[2,4,5].
Incidence rates of PVT while variable, are reported to be
as high as 16%[6]. The mechanism of PVT development
in cirrhosis is multifactorial and is due to a combination
of changes in liver architecture leading to impaired blood
flow and endothelial cell activation, hypercoagulability,
and the potential development of hepatocellular
carcinoma (HCC)[7]. The presence of PVT appears to be
associated with the severity of underlying liver disease
and hepatic decompensation from a mechanistic stand-
point. However, the field of coagulation disorders and
chronic liver disease is ever evolving and continues to
generate controversy, in particular, when consideration is
6. given to the impact of PVT on the development of hepatic
decompensation. Multiple studies have been published
indicating adverse clinical outcomes in the setting of
PVT in both transplant and non-transplant populations,
including hepatic decompensation, increased post-
transplant mortality, and decreased quality of life[7-10].
Others have argued that PVT does not affect clinically
relevant outcomes[11]. Due to this uncertainty, we sought
to determine the clinical impact of PVT on transplant free
survival and hepatic decompensation in adult patients
with cirrhosis.
MATERIALS AND METHODS
Literature search strategy and study selection
The investigators systematically searched the published
medical literature for observational studies and clinical
trials that compared mortality or hepatic decompensation
outcomes in cirrhosis patients with and without PVT. Pub-
lished studies were identified by searching the following
electronic databases: MEDLINE, Scopus, Science Citation
Index, AMED, and the Cochrane Library. The search
criteria included all publications through February 2015
with English language restriction. Electronic search
criteria included the following terms or keywords: “portal
vein thrombosis”, “mesenteric thrombosis”, “splanchnic
thrombosis”, “cirrhosis”, “mortality”, “decompensation”,
and “humans”. We reviewed the reference lists of
included articles in order to identify articles missed in
the database searches. Recent conference abstract lists
and other relevant grey literature sources were also
searched for examples of relevant studies using the
same terms and keywords. Studies were excluded if PVT
was associated with only malignancy, developed post-
procedure (surgery or interventional), were found in non-
cirrhotic patients with portal hypertension, were in LT-
only recipients, if no control/comparison group without
7. PVT was included, or if survival was not analyzed. This
study did not require institutional review board approval.
Data extraction
Two study personnel (Stine JG and Shah PM) inde-
pendently screened the abstracts and titles of all studies
identified using the electronic and manual search
criteria to identify studies meeting the inclusion criteria.
Each study meeting requirements of the first-round
inclusion criteria then underwent a full-text indepen-
dent review by both reviewers. Disagreements about
inclusion between reviewers were resolved by follow-up
consultation, and if necessary by a third clinical reviewer
(Cornella CL). Two reviewers independently extracted
the following data from each study that met inclusion
criteria: patient characteristics (age, gender, MELD,
and etiology of liver disease), study-level characteris-
tics (author, publication year, study design, enrollment
period, target population, total number of enrolled
2775 November 28, 2015|Volume 7|Issue
27|WJH|www.wjgnet.com
Stine JG et al . Portal vein thrombosis increases patient
mortality
patents, and percentage of patients with PVT) and
outcomes (mortality and hepatic decompensation).
Primary and secondary outcomes
Mortality was the primary outcome assessed. Secondary
outcomes included the presence of or development of
new gastroesophageal variceal bleeding, ascites, hepatic
encephalopathy, and an aggregate measure of the
8. occurrence of any of these three hepatic decompensation
outcomes.
Study quality and risk of bias assessment
The quality of observational studies was assessed
using the methods described by Stroup et al[12]. Only
studies deemed high-quality by the investigators were
included in the analysis. The Newcastle-Ottowa Quality
Assessment for Cohort Studies scale[13] was used to
further characterize the quality of studies based on
selection of study groups, comparability of groups, and
ascertainment of outcome. The studies are rated on
an 8-point scale separated by the three broad sections
delineated above.
Statistical analysis
Descriptive analysis of the studies identified, excluded,
and included, and meta-analysis of the reported study
effect measures, was conducted utilizing review manager
software (Rev-Man version 5.3; Copenhagen; The Nordic
Cochrane Centre; The Cochrane Collaboration; 2014).
We estimated pooled ORs and calculated corresponding
95%CIs using DerSimonian and Laird random-effects
models, which account for both between and within
study variability given that the included studies were
not functionally identical[14,15]. Between study variability
was separately assessed using the Cochran’s Q statistic
(with P < 0.05 considered significant). The proportion of
heterogeneity accounted for by between-study variability
was estimated using the I2 index and adjudicated to be
significant if I2 was > 75%[14,15]. A post-hoc funnel plot
was created to assess for the presence or absence of
publication bias.
RESULTS
Included studies
9. The electronic search criteria identified 226 studies.
After ensuring no duplicates were present, we screened
titles and abstracts. The full text of eleven studies was
assessed for eligibility. Following the qualitative systematic
review process, three observational studies met the
inclusion criteria for the current meta-analysis[7,16,17].
Of these, two were retrospective[7,17]. The third study
followed a prospective cohort of patients[16]. No additional
studies were appropriate for inclusion based on our
a-priori determined inclusion and exclusion criteria. Nery
et al[11] recently published a multicenter prospective
series of 1243 adult patients with cirrhosis without
baseline PVT in France and Belgium. About 118 patients
developed de novo PVT during a median follow-up period
of 47 mo. This study, while initially considered in full-
text review, was excluded specifically because absolute
numbers for mortality or individual types of hepatic
decompensation were not provided; rather, univariate
and multivariable analysis P-values were provided only
and only a composite of hepatic decompensation was
given in absolute number.
The 3 eligible reports evaluated cirrhotic patients that
did not initially have PVT, but developed it sometime over
the study period. They each excluded patients with HCC
and prior transplant. All 3 studies evaluated long-term
outcomes in cirrhotic patients with PVT compared to
cirrhotic patients without PVT. Study level characteristics
are found in Table 1. A summary of the search results is
presented in Figure 1, reflecting the reporting standards
of the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses[18].
The Englesbe et al[7] study assessed a total of 3295
(148 with PVT and 3147 without PVT) cirrhotic patients
10. between 1995-2007. The study assessed patients
that were being evaluated as candidates for liver trans-
plantation that had thrombus in the main portal vein
only. Patients with partial thrombus or thrombi in portal
vein branches, without extension into the main portal
vein were excluded. The Maruyama et al[17] article
evaluated a total of 150 patients with viral hepatitis, 42
had PVT (and 108 did not have PVT). The study by John
et al[16] found 290 patients with cirrhosis, 70 of these
had PVT and 220 did not. Notably, both the Maruyama
et al[17] and John et al[16] articles specified patients with
complete and partial thrombus, unlike the Englesbe
study[7].
In total, the three studies included 3735 cirrhotic
patients, 260 of which had PVT. Lengths of follow-up
ranged from less than one month to 136 mo, with mean
follow-ups ranging from 25 mo to 50 mo. Baseline
demographic characteristics were similar between PVT
and non-PVT groups in all 3 studies. There were no
differences in regards to race, age, gender, causes of
cirrhosis, or model for end stage liver disease (MELD)
scores. Demographic and etiologic characteristics of the
2776 November 28, 2015|Volume 7|Issue
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Table 1 Study level characteristics n (%)
Ref. Date published Dates enrolled Enrollment PVT Death - no
PVT Death - PVT
John et al[16] 2013 2004-2009 290 70 (24.1) 62 (28.2) 24
(34.3)
Maruyama et al[17] 2013 1998-2009 150 42 (28.0) 21
(19.4) 9 (21.4)
11. Englesbe et al[7] 2010 1995-2007 3295 148 (4.5) 1171 (37.2) 81
(54.7)
PVT: Portal vein thrombosis.
Stine JG et al . Portal vein thrombosis increases patient
mortality
2777 November 28, 2015|Volume 7|Issue
27|WJH|www.wjgnet.com
Maruyama et al[17] and John et al[16] both received 6/8.
The potential for publication bias was assessed using a
funnel plot of the relationship between reported effect
variance SE(log[OR]) and the reported study OR.
The plot illustrates the lack of evidence for potential
publication bias in the three studies-the study with the
largest effect size is the largest study included while the
smaller studies have lower effect sizes (Figure 2).
Portal vein thrombosis and mortality
The Englesbe et al[7] article demonstrated an incidence
rate of 4.5% for PVT. The patients with PVT were at
significantly higher risk of mortality with an OR of
2.04 (95%CI: 1.46-2.84) (Figure 3) Conversely, the
Maruyama et al[17] and John et al[16] studies found higher
rates of mortality between PVT and non-PVT subjects.
The OR for mortality for PVT in both studies were 1.13
and 1.27, respectively but these differences were non-
significant. Pooled analysis of the results reported across
all 3 studies demonstrates a significantly increased
risk of mortality in PVT patients (OR = 1.62, 95%CI:
1.11-2.36, P = 0.01). The Cochran’s Q statistic was non-
significant at P = 0.23 and I2 = 32%, demonstrating
12. non-significant heterogeneity of effects reported across
studies.
Portal vein thrombosis and hepatic decompensation
Secondary outcomes included episodes of hepatic
decompensation, including individual cases of ascites,
variceal bleeding, or portosystemic encephalopathy.
Both John et al[16] and Maruyama et al[17] demonstrated
similar effects of PVT on ascites development. John
et al[16] showed an OR of 1.51 (95%CI: 0.87-2.60)
compared to an OR of 7.46 (95%CI: 3.38-16.45) in the
Maruyama et al[17] study (Figure 4). The Englesbe et al[7]
study was excluded from this portion of analysis since
they did not report on rates of hepatic decompensation.
When the pooled OR was evaluated using random-
effects modeling, PVT continued to have statistically
patients included in each studies are summarized in
Table 2.
Bias assessment
All 3 studies include cohorts drawn from their abdominal
transplant clinic population. The patients were truly
representative of the average transplant population.
Exposed and unexposed patients (patients with cirrhosis
with spontaneous PVT and those without PVT) were
all drawn from their transplant clinic population and all
information was obtained through medical records in the
three studies. The Englesbe et al[7] study controlled for
PVT along with MELD, age, and presence of hepatitis C
virus in a multivariable logistic regression with survival
as the outcome. The Maruyama et al[17] study does not
include a model controlling for covariates. The John et
al[16] study does control for ascites and renal function,
however this study created a multivariable model to
identify predictors for PVT development. All three studies
13. had widely variable amounts of follow-up and there is
no information available on patients lost to follow-up
for any of the studies. Based on these characteristics,
the Englesbe et al[7] study received a score of 7/8, while
216 records identified through database searching
10 records identified through other sources
226 records screened
11 full text articles reviewed
3 studies included in review
215 records excluded
8 full text articles excluded
Id
en
ti
fic
at
io
n
Sc
re
en
in
g
14. El
ig
ib
ili
ty
In
cl
ud
ed
Reasons for exclusion
Different primary endpoint
No comparison group
Included malignancy
Different measure of association
No mortality information
Not limited to cirrhosis
Figure 1 The preferred reporting items for systematic reviews
and meta-analyses diagram. About 226 records were screened in
aggregate; 11 full text articles
were reviewed; 3 studies met inclusion criteria.
SE
(l
og
[O
R
])
15. 0.0
0.2
0.4
0.6
0.8
1.0
0.005 0.1 1 10 200
OR
Figure 2 Funnel plot assessing publication bias. No significant
publication
bias was observed in this study.
Stine JG et al . Portal vein thrombosis increases patient
mortality
2778 November 28, 2015|Volume 7|Issue
27|WJH|www.wjgnet.com
significant higher odds of hepatic decompensation (OR
= 2.52, 95%CI: 1.63-3.89, P < 0.001). The Cochran’s
Q statistic and I2 were both significant for heterogeneity
in this analysis. There was insufficient data available
to determine the pooled effect on other markers of
decompensation including gastroesophageal variceal
bleeding or hepatic encephalopathy.
DISCUSSION
16. Our systematic review and meta-analysis is the first
study to offer a pooled estimate and quantitative
assessment of the clinical impact of PVT in terms of
both mortality and hepatic decompensation. We have
demonstrated a significantly increased rate of mortality
for patients with cirrhosis and PVT when compared to
those patients without PVT. This finding is important
because PVT is a common finding in patients with
cirrhosis[4,6,19] and one that significantly impairs quality of
life and post-LT outcomes[7-9]. Several risk factors have
been suggested to increase the risk of PVT in patients
awaiting liver transplantation, including non-alcoholic
steatohepatitis[20].
The risk of hepatic decompensation with ascites for
patients with cirrhosis was also significantly greater
in the presence of PVT. Evaluating a pooled estimate
Table 2 Patient level characteristics n (%)
Englesbe 20101 John 20132 Maruyama 20133
No PVT (n = 3147) PVT (n = 148) No PVT (n = 220) PVT (n
= 70) No PVT (n = 108) PVT (n = 42)
Sex (M/F) 1905/1242 91/57 144/76 42/28 63/45 22/20
Race
Black 218 (6.9) 7 (4.7) - - - -
White - - 184 (83.6) 60 (85.7) - -
Other 2545 (80.9) 131 (88.5) - -
"Nonblack" "Nonblack" - -
Etiology
AIH 95 (3) 8 (5.4) - - - -
Biliary/cholestatic 173 (5.4) 7 (5.4) 24 (11) 5 (7.1) - -
Alcohol 672 (21.4) 31 (20.9) 37 (16.9) 5 (7.1) - -
17. Viral 1253 (39.8) 50 (34.1) 62 (28.3) 16 (27.1) 108 42
Cryptogenic/NASH 72 (2.3) 0 35 (16) 12 (17.1) - -
Other 449 (14.3) 22 (14.9) 37 (16.9) 20 (28.6) - -
Age (yr) 51.5 ± 11.2 50.9 ± 10.8 55.8 ± 9.1 58.4 ± 8.8 63.3 ±
8.68 62.4 ± 11
MELD 12.1 ± 7.2 13.3 ± 8.3 13.8 ± 4.5 14.9 ± 5.9 10.2
10.6
1Presence of PVT at time of initial transplant evaluation or
during the pre-transplant period; 2PVT category includes
patients with PVT at baseline (n = 47)
and those that developed new PVT during the study period (n =
23); 3Study only assessed patients with viral hepatitis. No data
reported for race. PVT:
Portal vein thrombosis; MELD: Model for end stage liver
disease; NASH: Non-alcoholic steatohepatitis; M/F:
Male/female; AIH: Autoimmune hepatitis.
PVT No PVT Odds ratio Odds ratio
Study or subgroup Events Total Events Total Weight M-H,
random, 95%CI M-H, random, 95%CI
Englesbe et al 81 148 1171 3147 54.8% 2.04 (1.46, 2.84)
John et al 24 70 64 220 29.7% 1.27 (0.72, 2.26)
Maruyama et al 9 42 21 108 15.4% 1.13 (0.47, 2.72)
Total (95%CI) 260 3475 100.0% 1.62 (1.11, 2.36)
Total events 114 1256
Heterogeneity: Tau2 = 0.04; χ 2 = 2.96, df = 2 (P = 0.23); I 2 =
32%
Test for overall effect: Z = 2.50 (P = 0.01) 0.01 0.1
1 10 100
Favours no PVT Favours PVT
Figure 3 Portal vein thrombosis and mortality. PVT is
associated with an increased pooled risk of death in the absence
18. of significant heterogeneity. PVT: Portal
vein thrombosis.
PVT No PVT Odds ratio Odds ratio
Study or subgroup Events Total Events Total Weight M-H,
fixed, 95%CI M-H, fixed, 95%CI
John et al 2013 31 70 76 220 83.0% 1.51 (0.87, 2.60)
Maruyama et al 2013 27 42 21 108 17.0% 7.46 (3.38,
16.45)
Total (95%CI) 112 328 100.0% 2.52 (1.63, 3.89)
Total events 58 97
Heterogeneity: χ 2 = 10.63, df = 1 (P = 0.001); I 2 = 91%
Test for overall effect: Z = 4.17 (P < 0.0001) 0.05 0.2
1 5 20
Favours no PVT Favours PVT
Figure 4 Portal vein thrombosis and ascites. PVT is associated
with an increased pooled risk of hepatic decompensation
manifested as ascites. This conclusion
may be limited by heterogeneity in the included studies. PVT:
Portal vein thrombosis.
Stine JG et al . Portal vein thrombosis increases patient
mortality
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27|WJH|www.wjgnet.com
of risk for gastroesophageal variceal hemorrhage or
ascites resulting from PVT could not be performed due
to the lack of data reporting by the included studies.
While this has been shown in other studies, these were
19. not included due to a lack of a comparison group.
PVT appears to increase mortality and hepatic
decompensation (composite as well as variceal hemorr-
hage and ascites), however, the relatively small number
of included studies limits generalizable conclusions. Our
study has several other limitations. Multiple studies with
a large number of patients were excluded due to a lack
of a comparison group, and our literature search revealed
a general lack of randomized controlled trials within
the context of PVT. The large multicenter prospective
study by Nery et al[11] was specifically excluded due
to a lack of absolute numbers and component hepatic
decompensation assessment. The inclusion of only
three studies also limits the systematic assessment
for publication bias and may also have resulted in the
large degree of heterogeneity seen in calculation of the
pooled measure of effect for PVT and the development of
ascites.
Regardless, this current review represents the
best available summary of the evidence to date and
highlights a significant need for future research around
the implications of PVT, especially prospective studies
with a direct comparator group. Safety and efficacy data
on both prevention and treatment of PVT is in general
lacking. Villa et al[21] recently published their unblinded
randomized, single center experience having found that
daily prophylactic dosing of low molecular weight heparin
(the equivalent of 40 mg/d) for twelve months prevented
the development of PVT in patients with compensated
cirrhosis. While the study was terminated at 48 wk,
the effect persisted through follow-up at 5 years when
compared to standard of care[21]. Additionally, the authors
demonstrated less hepatic decompensation in the low
molecular weight heparin arm (P < 0.0001) and a more
20. importantly, a significant survival benefit[21]. Building
on this work, Cui et al[22] published their single center
randomized trial of 65 patients investigating therapeutic
doses of low-molecular weight heparin (1 mg/kg every
twelve hours or 1.5 mg/kg daily), where 78.5% (n = 51)
responded to treatment with either complete or partial
recanalization at 6 mo after starting therapy. These
responders had regression of their liver disease when
compared directly to the 14 non-responders. Similar to
Villa et al[21], Cui et al[22] found no episodes of variceal
hemorrhage, however, they did find much higher rates
of non-variceal bleeding (6.4%-23.5%). While this
study has several limitations including its generalizability
as it only enrolled hepatitis B patients in China, it is
nonetheless promising. With the development of new oral
anticoagulants, the promise of treatment and possibly
prevention is becoming a reality[23]. More rigorous
study is needed in the field of coagulation disorders
in a randomized, placebo controlled interventional
or preventative trial with a direct comparator group
using either heparin based or new direct acting oral
anticoagulant therapy.
In conclusion, PVT appears to increase mortality
and hepatic decompensation from ascites, however,
the relatively small number of included studies limits
generalizable conclusions and contributes significant
heterogeneity in the pooled measures of effect. More
prospective, randomized placebo controlled trials with a
direct comparator group are needed.
COMMENTS
Background
Non-neoplastic portal vein thrombosis is a common
complication of cirrhosis.
21. Treatment options carry risk and are not without complications.
To make
appropriate clinical decisions, clinicians need to be cognizant of
the available
evidence.
Research frontiers
The field of coagulation disorders in chronic liver disease is
ever expanding.
Much of the research focuses on portal vein thrombosis and
clinically relevant
outcomes with the goal of preventing hepatic decompensation
through either
prevention or treatment of portal vein thrombosis.
Innovations and breakthroughs
In the present study, the authors investigated the impact of
portal vein throm-
bosis on mortality and hepatic decompensation in patients with
cirrhosis. This is
the first report of a meta-analysis in patients with cirrhosis
specifically excluding
those who go on to receive liver transplantation.
Applications
The present report furthers understanding regarding the clinical
importance of
portal vein thrombosis in patients with underlying cirrhosis.
Peer-review
This systematic review and meta-analysis adds useful
information for both
clinical practice and further academic research with the goal of
impacting
patient centered outcomes.
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