Watch free Varizen

Watch free Varizen



Watch free Varizen

N Engl J Med ; Comments open through January 8, The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. Full Text of Background We enrolled patients with severe acute upper gastrointestinal bleeding and randomly assigned of them to a restrictive strategy watch free Varizen when the hemoglobin level fell below 7 g per deciliter and to a liberal strategy transfusion when the hemoglobin fell below 9 g per deciliter.

Randomization was stratified according to the presence or absence of liver cirrhosis, watch free Varizen. Full Text of Methods The probability watch free Varizen survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer hazard ratio, 0. Full Text of Results As compared with a liberal transfusion strategy, watch free Varizen, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding.

Full Text of Discussion Acute upper gastrointestinal bleeding is a common emergency condition associated with high morbidity and mortality. Transfusion may be lifesaving in patients with massive exsanguinating bleeding. However, in most cases hemorrhage is not so severe, and in such circumstances the safest and most effective transfusion strategy is controversial. Restricted transfusion strategies may be appropriate in some settings.

Controlled trials have shown that for critically ill patients, a watch free Varizen transfusion strategy is at least as effective as a liberal strategy, while substantially reducing the use of blood supplies. Observational studies and small controlled trials have suggested that transfusion may be harmful in patients with hypovolemic anemia, watch free Varizen, 6,7 even in those with gastrointestinal bleeding. We performed a randomized, controlled trial in which we assessed whether a restrictive threshold for red-cell transfusion watch free Varizen patients with acute gastrointestinal bleeding was safer and more effective than a liberal transfusion strategy that was based on the threshold recommended in guidelines at the time the study was designed.

From June through Decemberwe consecutively enrolled patients with gastrointestinal bleeding who were admitted to Hospital de la Santa Creu i Sant Pau in Barcelona. Written informed consent was obtained from all the patients or their next of kin, and the trial was approved by the institutional ethics committee at the hospital.

The protocolincluding the statistical analysis plan, is available with the full text of this article at NEJM. No commercial support was involved in the study. All the authors vouch for the integrity and the accuracy of watch free Varizen analysis and for the fidelity of the study to the protocol.

No one who is not an author contributed to the manuscript. Patients older than 18 years of age who had hematemesis or bloody nasogastric aspiratemelena, or both, as confirmed by the hospital staff, were considered for inclusion. Patients were excluded if they declined to undergo a blood transfusion. Additional exclusion criteria were massive exsanguinating bleeding; an acute coronary syndrome, symptomatic peripheral vasculopathy, stroke, transient ischemic attack, or transfusion within the previous 90 days; a recent history of trauma or surgery; lower gastrointestinal bleeding; a previous decision on the part of the watch free Varizen physician that the watch free Varizen should avoid specific medical therapy; and a clinical Rockall score of 0 with a hemoglobin level higher than 12 g per deciliter.

The Rockall score is a system for assessing the risk of further bleeding or death among patients with gastrointestinal bleeding; scores range from 0 to 11, with a score of 2 or lower indicating low risk and scores of 3 to 11 indicating increasingly greater risk.

Immediately after admission, patients were randomly assigned to a restrictive transfusion strategy or a liberal transfusion strategy. Randomization was performed with the use of computer-generated random numbers, with the group assignments placed in sealed, consecutively numbered, opaque envelopes.

Randomization was stratified according to the presence or absence of liver cirrhosis and was performed in blocks of four. Cirrhosis was diagnosed according to clinical, biochemical, and ultrasonographic findings.

In the restrictive-strategy group, the hemoglobin threshold for transfusion was 7 g per deciliter, with a target range for the post-transfusion hemoglobin level of watch free Varizen to 9 g per deciliter. In the liberal-strategy group, watch free Varizen, the hemoglobin threshold for transfusion was 9 g per deciliter, with a target range for the post-transfusion hemoglobin level of 9 to watch free Varizen g watch free Varizen deciliter.

In both groups, 1 unit of red cells was transfused initially; the hemoglobin level was assessed after the transfusion, watch free Varizen, and an additional unit was transfused if the hemoglobin level was below the threshold value.

The transfusion protocol was applied until the patient's discharge from the hospital or death. The protocol allowed for a transfusion to be administered any time symptoms or signs related to anemia developed, massive bleeding occurred during follow-up, watch free Varizen, or surgical intervention was required.

Only prestorage leukocyte-reduced units of packed red cells were used for transfusion, watch free Varizen. Hemoglobin levels were measured after admission and again every 8 hours during the first 2 days and every day thereafter.

Hemoglobin levels were also assessed when further bleeding was suspected. All the patients underwent emergency gastroscopy within the first 6 hours. When endoscopic examination disclosed a nonvariceal lesion with active arterial bleeding, a nonbleeding visible vessel, or an adherent clot, patients underwent endoscopic therapy with injection of adrenaline plus multipolar electrocoagulation or application of endoscopic clips, watch free Varizen.

Patients with peptic ulcer received a continuous intravenous infusion of omeprazole 80 mg per hour period after an initial bolus of 80 mg for the first 72 hours, followed by oral administration of omeprazole. Bleeding esophageal varices were also treated with band ligation or with sclerotherapy, and gastric varices with injection of cyanoacrylate. In patients with variceal bleeding, portal pressure was measured within the first 48 hours and again 2 to 3 days later to assess the effect of the transfusion strategy on portal hypertension.

Portal pressure was estimated with the use of the hepatic venous pressure gradient HVPGas described elsewhere. The primary outcome measure was the rate of death from any cause within the first 45 days. Secondary outcomes included the rate of further bleeding and the rate of in-hospital complications. Further bleeding was considered to indicate therapeutic failure; if the bleeding involved nonvariceal lesions, the patient underwent repeat endoscopic therapy or emergency surgery, whereas in the case of further variceal bleeding, transjugular intrahepatic portosystemic shunting TIPS was considered.

Complications were defined as any untoward events that necessitated active therapy or prolonged hospitalization. Side effects were considered to be severe if the health or safety of the patient was endangered. The statistical analysis was performed according to the intention-to-treat principle, watch free Varizen.

Standard tests were used for comparisons of proportions and means, watch free Varizen. Continuous variables are expressed as means and standard deviations. Actuarial probabilities were calculated with the use of the Kaplan—Meier method and were compared with the use of the watch free Varizen test.

A Cox proportional-hazards regression model was used to compare the two transfusion-strategy groups with respect to the primary and secondary end points, with adjustment for baseline risk factors see the Supplementary Appendixavailable at NEJM. Data were censored at the time an end-point event occurred, at the patient's last visit, or at the end of the day follow-up period, watch free Varizen, whichever watch free Varizen first.

Prespecified subgroup analyses were performed to assess the efficacy of transfusion strategies according to the source of bleeding lesions related to portal hypertension or peptic ulcer. All P values are two-tailed. Calculations were performed with the use of the SPSS statistical package, version During the study period, patients were admitted to the hospital for gastrointestinal bleeding and were screened.

Of these, 41 declined to participate and were excluded; among the reasons for exclusion were exsanguinating bleeding requiring transfusion in 39 patients and a low risk of rebleeding patients Figure 1 Figure 1 Screening, Randomization, and Follow-up. During the study period, patients with gastrointestinal bleeding were screened, and patients were excluded.

The reasons for exclusion included massive exsanguinating bleeding requiring transfusion before randomization 39 patients and a low Salbe oder Gel aus Krampf Bewertungen of rebleeding patients.

A low risk of rebleeding was defined as a clinical Rockall score of 0 and hemoglobin levels higher than 12 g per deciliter. The Rockall score is a system for assessing the risk of further bleeding or death among patients with gastrointestinal bleeding; scores range from 0 watch free Varizen 11, with higher scores indicating greater risk.

Patients were also excluded if they declined watch free Varizen transfusion 14 patients ; other exclusion criteria were an acute coronary syndrome 58watch free Varizen, symptomatic peripheral vasculopathy 12stroke or transient ischemic attack 7or transfusion 10 within the previous 90 days; lower gastrointestinal bleeding 51 ; pregnancy 3 watch free Varizen a recent history of trauma or surgery 41 ; a decision by the attending physician that the patient should avoid medical therapy 9 ; or inclusion in this study within the previous 90 days or inclusion more than twice A total of patients underwent randomization, of whom 32 were withdrawn: A total of patients underwent randomization and 32 withdrew or were withdrawn by the investigators after randomization see Figure 1 for detailsleaving patients in the restrictive-strategy group and in the liberal-strategy group for the intention-to-treat analysis.

The baseline characteristics were similar in the two groups Table 1 Table 1 Baseline Characteristics of the Patients. The hemoglobin concentration at admission was similar in the two groups Table 2 Table 2 Hemoglobin Levels, Transfusions, and Watch free Varizen. The percentage of patients in whom the lowest hemoglobin level was less than 7 g per deciliter was higher in the restrictive-strategy group than in the liberal-strategy group, watch free Varizen.

The hemoglobin concentration at 45 days was similar in the two groups. The percentage of patients who received a transfusion of fresh-frozen plasma, the percentage of patients who received a transfusion of platelets, and the total amount of fluid administered were similar in the two groups. Mortality at 45 watch free Varizen was significantly lower in the restrictive-strategy group than in the liberal-strategy group: Panel A shows the Kaplan—Meier estimates of the 6-week survival rate in the two groups.

The probability of survival was significantly higher in the restrictive-strategy group than in the liberal-strategy group. The gray arrows indicate the day on which data from a patient were censored. The inset shows the same data on an enlarged y axis. The risk of death was virtually unchanged after adjustment for watch free Varizen risk factors for death hazard ratio with restrictive strategy, 0. Among all patients with cirrhosis, the risk of death was slightly lower in the restrictive-strategy group than in the liberal-strategy group Figure 2.

In the subgroup of patients with cirrhosis and Child—Pugh class A or B disease, the risk of death was significantly lower among patients in the restrictive-strategy group than among those in the liberal-strategy group, whereas in the subgroup of watch free Varizen with cirrhosis and Child—Pugh class C disease, the risk was similar in the two groups, watch free Varizen.

Among patients with bleeding from a peptic ulcer, the risk of death was slightly lower with the restrictive strategy than with the liberal strategy. Death was due to unsuccessfully controlled bleeding in 3 watch free Varizen 0. Death was caused by complications of treatment in 3 Sahnekönigs Gang mit Schungit von Krampfadern 2 in the liberal-strategy group and 1 in the restrictive-strategy group.

In the remaining 44 patients 19 in the restrictive-strategy group and 25 in the liberal-strategy grouphemorrhage was controlled and death was due to associated diseases, watch free Varizen. The rate of further bleeding was significantly lower in the restrictive-strategy group than in the liberal-strategy group: The risk of further bleeding was significantly lower with the restrictive watch free Varizen after adjustment for baseline risk factors watch free Varizen further bleeding hazard ratio, 0.

In addition, the length of hospital stay was shorter in the restrictive-strategy group than in the liberal-strategy group. In the subgroup of patients with cirrhosis, the risk of further bleeding was lower with the restrictive transfusion strategy than with the liberal transfusion strategy among patients with Child—Pugh class A or B disease watch free Varizen was similar in the two groups among patients with Child—Pugh class C disease Table 3.

Rescue therapy with balloon watch free Varizen or with transjugular intrahepatic portosystemic shunt was required less frequently in the restrictive-strategy group than in the liberal-strategy group. A baseline hepatic hemodynamic study was performed in 86 patients in the restrictive-strategy group and in 89 in the liberal-strategy group, and it was repeated 2 to 3 days later in 74 and 77 patients, respectively, to assess changes. Patients in the liberal-strategy group had a significant increase in the mean hepatic venous pressure watch free Varizen between the first hemodynamic study and the second from There was no significant change in mean hepatic venous pressure gradient in the restrictive-strategy group during that interval, watch free Varizen.

Among patients with bleeding from a peptic ulcer, there was a trend toward a lower risk of further bleeding in the restrictive-strategy group Table 3. Transfusion reactions and cardiac events, mainly pulmonary edema, occurred more frequently in the liberal-strategy group Table 3. The rates of other adverse events, such as acute kidney injury or bacterial infections, did not differ significantly between the groups Table S5 in the Supplementary Watch free Varizen. We found that among patients with severe acute upper gastrointestinal bleeding, watch free Varizen, the outcomes were significantly improved with a restrictive transfusion strategy, in which the hemoglobin threshold was 7 g per deciliter, as compared with a liberal transfusion strategy, in which the hemoglobin threshold was 9 g per deciliter, watch free Varizen.


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N Engl J Med ; Patients with cirrhosis in Child—Pugh class C or those in class B who have persistent bleeding at endoscopy are at high risk for treatment failure and a poor prognosis, even if they have undergone rescue treatment with a transjugular intrahepatic portosystemic shunt TIPS.

This study evaluated the earlier use of TIPS in such patients. Full Text of Background We randomly assigned, watch free Varizen, within 24 hours after watch free Varizen, a total of 63 patients with cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy to treatment with a polytetrafluoroethylene-covered stent within 72 hours after randomization early-TIPS group, 32 patients or continuation of vasoactive-drug therapy, followed after 3 to 5 days by treatment with propranolol or nadolol and long-term endoscopic band ligation EBLwith insertion of a TIPS if needed as rescue therapy pharmacotherapy—EBL group, 31 patients.

Full Text of Methods The number of days in the intensive care unit and the percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy—EBL group than in the early-TIPS group.

No significant differences were observed between the two treatment groups with respect to serious adverse events. Full Text of Results In these patients with watch free Varizen who were hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated watch free Varizen significant reductions in treatment failure and in mortality. Full Text of Discussion Variceal bleeding is a severe complication of portal hypertension and a major cause of death in patients with cirrhosis.

Advanced liver failure, watch free Varizen, failure to control variceal bleeding, early rebleeding, and marked elevations in portal pressure are associated with increased mortality. In a study involving patients at high risk for treatment failure, as indicated by a hepatic venous pressure gradient of 20 mm Hg or more, 11 early treatment with TIPS improved the prognosis in comparison with medical treatment in a study by Monescillo et al.

We conducted a study to determine whether early treatment with TIPS, with the use of a stent covered with extended polytetrafluoroethylene e-PTFEcan improve outcomes in patients with cirrhosis and variceal bleeding who are at high risk for treatment failure and death.

Eligible patients had cirrhosis with acute esophageal variceal bleeding that was being treated with a combination of vasoactive drugs, watch free Varizen, endoscopic treatment, and prophylactic antibiotics.

Patients had Child—Pugh class C disease a score of 10 to 13 or they had class B disease Varizen und lila score of 7 to 9 but with active bleeding at diagnostic endoscopy. Patients with scores higher than 13 were excluded from the study, watch free Varizen.

In the Child—Pugh classification of liver disease, class A [a score of 5 or 6] indicates the least severe disease, class B [7 to 9] moderately severe disease, and class C [10 to 15] the most severe disease. Active variceal bleeding at endoscopy was defined on the basis of the Baveno criteria.

Exclusion criteria were an age of more than 75 years, pregnancy, hepatocellular carcinoma that did not meet the Milano criteria for transplantation i. All patients provided written informed consent. The study protocol was approved by the ethics committees of all participating hospitals and followed the Guidelines for Good Clinical Practice watch free Varizen clinical trials.

Randomization was performed watch free Varizen 24 hours after admission. The randomization sequence was generated by computer with the use of a concealed block size of four.

The coded treatment assignments were kept at the coordinating center in sealed, consecutively numbered, opaque envelopes. Randomized assignments to the study groups were made by contacting the coordinating center available 24 hours a day by telephone or fax, watch free Varizen.

Treatment with vasoactive drugs was continued until patients were free of bleeding for at least 24 hours and preferably up to 5 days, watch free Varizen, at which point treatment with a nonselective beta-blocker either propranolol or nadolol was started. The dose was increased in a stepwise fashion every 2 to 3 days to the maximum tolerated dose or to a maximum of mg twice daily for propranolol and mg per day for nadolol, watch free Varizen.

After these doses were achieved, 10 mg of isosorbidemononitrate was initiated at bedtime, with a stepwise increase in the dose to a maximum of 20 mg twice a day or the maximum tolerated watch free Varizen. In addition, within 7 to 14 days after the initial endoscopic treatment, the second, watch free Varizen, elective session of EBL was performed.

EBL sessions were then scheduled every 10 to 14 days until variceal eradication was achieved i. Patients received proton-pump inhibitors until variceal eradication was accomplished.

After eradication, endoscopic monitoring was performed at 1-month, 6-month, and month intervals and then annually. If varices reappeared, further EBL sessions were initiated. Treatment failure was defined as one severe rebleeding episode i. TIPS was performed within 72 hours after diagnostic endoscopy or, when possible, within the first 24 hoursand vasoactive drugs were administered until then. If the portal-pressure gradient the difference between portal-vein pressure and inferior vena caval pressure did not decrease to below 12 mm Hg, the stent was dilated to 10 mm.

Follow-up visits were scheduled at 1 month, at 3 months, and every 3 months thereafter. Doppler ultrasonography was performed at the first visit, watch free Varizen, at 6 months, watch free Varizen, and every 6 months thereafter.

Thrombophlebitis ist ein Problem were followed until death or liver transplantation up to a maximum of 2 years of follow-up or until the end of the study September The primary end point of the study was a composite outcome of failure to control acute bleeding or failure to prevent clinically watch free Varizen variceal rebleeding within 1 year after enrollment.

Secondary end points were mortality at 6 weeks and at 1 year, failure to control acute bleeding, watch free Varizen, early rebleeding rate of rebleeding at 5 days and at 6 weeksrate of rebleeding between 6 weeks and 1 year, the development of other complications related to portal hypertension on follow-up, the number of days in the intensive care unit, the percentage of follow-up days spent in the hospital, and the use of alternative treatments, watch free Varizen.

In a study by Villanueva et al. Because the only rationale for early use of TIPS would be evidence that this approach is better than the current standard treatment, the sample size was calculated with the use of a one-sided test. All data analyses were performed on an intention-to-treat basis according to a preestablished analysis plan. Dichotomous variables were compared by means of Fisher's exact test, and continuous variables were watch free Varizen by means of the nonparametric Mann—Whitney rank-sum test, watch free Varizen.

The probabilities of reaching the primary end point and of survival were estimated by the Kaplan—Meier method and were compared by means of the log-rank test. A P value of less than 0, watch free Varizen.

The statistical software packages used for the analysis were SPSS version We screened patients with acute variceal bleeding who were admitted to the participating hospitals for study eligibility.

There were no significant differences in baseline characteristics between the two groups at the time of entry into the study Table 1 Table 1 Baseline Characteristics of the Patients. A total of 7 patients 3 in the pharmacotherapy—EBL group and 4 Krampfadern Strümpfe nach Preis Krasnodar the early-TIPS group were lost to follow-up after a median of 8 months range, 0.

A total of 6 patients 2 in the pharmacotherapy—EBL group and 4 in the early-TIPS group underwent liver transplantation during follow-up. In the pharmacotherapy—EBL group, 22 patients received propranolol median dose, 55 mg [range, 10 to ]and only 3 received nadolol.

In the remaining 6 patients, nonselective beta-blocker therapy was not initiated because of failure to control bleeding, early rebleeding, or death. In 12 patients, isosorbidemononitrate was added to the nonselective beta-blocker median dose, 25 mg [range, 10 to 40]but it was not added in 13 patients because of arterial hypotension, watch free Varizen, the treating physician's preference, or early death.

Variceal eradication was achieved in 12 patients after a watch free Varizen of 2 EBL sessions range, 1 to 7 without rebleeding; in 4 patients, watch free Varizen, eradication was achieved after treatment of a rebleeding episode with additional EBL sessions. In the remaining 15 patients, eradication was not achieved in 12 because the primary end point was reached [resulting in rescue TIPS in 7 and death in 5], in 2 who were lost to follow-up, and in 1 despite eight EBL sessions.

In the early-TIPS group, watch free Varizen but 1 patient, who withdrew consent, underwent early shunt placement. There were no technical failures or major complications of the TIPS procedure. Paroxysmal supraventricular tachycardia occurred in 1 patient and was controlled medically.

A total of watch free Varizen patients required one stent, and 4 required two stents. The mean portal-pressure gradient dropped from Despite dilation to 10 mm, the portal-pressure gradient after TIPS remained above 12 mm Hg in 2 patients. Collateral embolization was performed in 2 patients one of whom had a portal-pressure gradient above 12 mm Hg after TIPS. The probability of remaining free from uncontrolled variceal bleeding or variceal rebleeding is shown in Panel A, and the probability of survival is shown in Panel B.

In these patients, the Model for End-Stage Liver Disease MELD score which ranges from 6 to 40, with higher scores indicating more severe disease increased from a mean of In 7 of these patients, TIPS with an e-PTFE—covered stent was used as rescue therapy; although bleeding was controlled, 4 of these patients died within 36 days range, 1 to In 5 patients, no further treatment was considered because of severe liver failure, and all died, watch free Varizen.

In the 9 patients who died, watch free Varizen, the mean MELD score was The remaining 2 patients who reached the primary end point underwent additional EBL sessions and were alive at the end of the follow-up period. An additional 4 patients 3 in the pharmacotherapy—EBL group and 1 in the early-TIPS group had a rebleeding episode that was not clinically significant i. Causes of death are summarized in Table 2.

In the pharmacotherapy—EBL group, 12 patients had a total of 17 episodes of Strumpfhosen Strümpfe Krampfadern aus Bewertungen encephalopathy, whereas in the early-TIPS group, 8 patients had a total of watch free Varizen episodes Table 3 Table 3 Adverse Events.

Most of these episodes occurred during the index bleeding. A total of 3 patients in the pharmacotherapy—EBL group and 2 in the early-TIPS group had stage III hepatic encephalopathy, and 1 patient in each group had mild, recurrent hepatic encephalopathy. Spontaneous bacterial peritonitis developed during the index bleeding in 2 patients in the pharmacotherapy—EBL group, both of whom died.

In addition, the hepatorenal syndrome developed during the index bleeding in 7 patients: As shown in Table 3there were no significant between-group differences in the numbers of patients who had adverse effects. In the study by Monescillo et al.

Therefore, it is difficult to extrapolate the results of this study for application to clinical practice. Our study was specifically designed to show whether an early decision to use TIPS, with e-PTFE—covered stents and based on clinical criteria, can improve the prognosis for patients with variceal bleeding who are at high risk.

We found that in patients treated early with TIPS, watch free Varizen risks of failure to control bleeding and of variceal rebleeding were reduced.

In addition, and even watch free Varizen important, the early use of TIPS was associated with a reduction in mortality. This watch free Varizen effect on survival was observed even though rescue TIPS was used in patients in whom medical treatment failed.

Mortality was very high Krampfadern an den Penis es the patients who underwent rescue TIPS after treatment failure, a result that is consistent with the findings in previous studies.

Previous studies evaluating the role of TIPS in the prevention of recurrent variceal bleeding clearly showed that TIPS reduces the rebleeding rate but increases hepatic encephalopathy without improving survival. It should be noted Krampfadern und Verstopfung previous studies of TIPS differed from our study in that they used bare stents or did not limit enrollment to watch free Varizen at high risk for treatment failure.

In the study watch free Varizen Escorsell et al, watch free Varizen. Therefore, the study design precluded the possibility of demonstrating a benefit of TIPS in these high-risk patients.

In high-risk patients, the potentially deleterious effects of e-PTFE—covered TIPS appear to be counterbalanced by its high efficacy in controlling bleeding and thus preventing further clinical deterioration.

In contrast, TIPS should not be used as the initial treatment in patients with Child—Pugh class A disease, since the rates of medical-treatment failure and mortality are low among such patients. Although the risks of treatment failure and death were higher in patients with Child—Pugh class C disease than in those with class B disease, our trial was not powered to conduct appropriate subgroup analyses.

Therefore, further evaluation will be needed to determine whether the early use of TIPS equally watch free Varizen these two subgroups of patients. The early use of TIPS was not associated with an increase in the number or severity of watch free Varizen of hepatic encephalopathy. In conclusion, in patients with Child—Pugh class C disease or class B disease with active bleeding who were admitted for acute variceal bleeding, the early use of TIPS with an e-PTFE—covered stent was associated with significant reductions in the failure to control bleeding, in rebleeding, and in mortality, with no increase in the risk of hepatic encephalopathy.

Lalemanand an educational grant from Gore. Caca, receiving lecture fees and reimbursement for travel expenses from Gore; and Dr.


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