Sydämen hypertrofian ja kroonisen vajaatoiminnan farmakologinen hoito

Sydämen krooninen vajaatoiminta on merkittävä maailmanlaajuinen ongelma. Se on erilaisten sydän- ja verisuonisairauksien aiheuttama monimuotoinen oireyhtymä. Sydämen vasemman kammion hypertrofia eli sydämen seinämien paksuuntuminen on yksi keskeinen tekijä, joka voi olla sydämen vajaatoiminnan taustalla. Kohonnut verenpaine on yleisin syy, joka johtaa sydänlihaksen paksuuntumiseen. Tämä johtaa sydämen pumppaustoiminnan häiriintymiseen, erilaisten neurohormonaalisten mekanismien aktivaatioon ja edelleen sydämen vajaatoimintaan. Sydämen vajaatoiminnan neurohormonaalisista mekanismeista tärkeimmät ovat reniini-angiotensiini-aldosteroni-järjestelmän ja sympaattisen hermoston aktivaatio, sydämen rakenteiden uudelleenmuovautuminen, sydänlihassolujen apoptoosi ja systeeminen tulehdustila. Sydämen hypertrofiaa ja sen syntymistä pyritään estämään kohonneen verenpaineen lääkehoidolla. Reniini-angiotensiini-aldosteronijärjestelmällä on keskeinen merkitys sydämen vajaatoiminnassa. Sydämen vajaatoiminnan ennusteeseen vaikuttavista lääkeaineista angiotensiinikonvertasin estäjät (ACEestäjät) ovat säilyttäneet johtoasemansa jo vuosikymmenten ajan. Angiotensiinireseptoreiden salpaajien (AT1-salpaajien) odotettiin syrjäyttävän ACE-estäjät sydämen vajaatoiminnan hoidossa, mutta toistaiseksi niitä pidetään vain vaihtoehtoisina lääkkeinä. Sympaattisen hermoston aktivaatiota vähentävät β-salpaajat ovat vakiinnuttaneet asemansa toiseksi tärkeimpänä lääkeryhmänä. Diureetit ovat paljon käytetty lääkeaineryhmä sydämen vajaatoiminnan hoidossa, mutta niistä ainoastaan aldosteroniantagonisteilla on tutkitusti ennustetta parantavaa vaikutusta. Kroonisen vajaatoiminnan hoidossa käytetään edelleen myös digoksiinia. Tulevaisuudessa sydämen vajaatoiminnan ennusteeseen vaikuttavia lääkeaineita voivat olla reniinin estäjät, neutraaliendopeptidaasin estäjät, vasopressiinin antagonistit tai inflammatroisiin sytokiineihin vaikuttavat molekyylit. Erikoistyön kokeellisessa osiossa tarkoituksena oli tutkia sydämen hypertrofian kehittymistä vatsa-aortta kuristetuilla rotilla ja kalsiumherkistäjä levosimendaanin sekä AT1-salpaaja valsartaanin vaikutuksia hypertrofian kehittymiseen. Kokeellisessa osiossa arvioitiin myös sydämen hypertrofian ja vajaatoiminnan jyrsijämallina käytetyn vatsa-aortan kuristuksen (koarktaation) toimivuutta ja vaikutuksia ultraäänen avulla määritettyihin kardiovaskulaarisiin parametreihin. Vatsa-aortta kuristettiin munuaisvaltimoiden yläpuolelta. Kuristus saa aikaan verenpaineen kohoamisen ja sydämen työtaakan lisääntymisen. Pitkittyessään tila johtaa sydänlihaksen hypertrofiaan ja vajaatoimintaan. 64 eläintä jaettiin ryhmiin, siten että jokaiseen ryhmään tuli kahdeksan eläintä. Ryhmistä kolmelle annettiin lääkeaineena levosimendaania kolmella eri päiväannoksella (0,01 mg/kg; 0,10 mg/kg; 1,00 mg/kg) ja kolmelle valsartaania kolmella eri päiväannoksella (0,10 mg/kg; 1,00 mg/kg; 10,00 mg/kg) juomaveden mukana. Lääkitys aloitettiin leikkauksen jälkeen ja jatkettiin kahdeksan viikon ajan. Kardiovaskulaariset parametrit, kuten isovolumetrinen relaksaatioaika (IVRT), vasemman kammion läpimitta systolessa ja diastolessa sekä seinämäpaksuudet, ejektiofraktio (EF), supistuvuusosuus (FS), minuuttitilavuus (CO) ja iskutilavuus (SV) määritettiin kahdeksan viikon kuluttua leikkauksesta ultraäänitutkimuksen avulla. Lisäksi määritettiin eläinten sydämen paino suhteessa ruumiin painoon. Tuloksia verrattiin ilman lääkehoitoa olleeseen koarktaatioryhmään. Eläinmallin toimivuutta arvioitiin vertaamalla koarktaatioryhmän tuloksia sham-operoidun ryhmän tuloksiin. Levosimendaanilla havaittiin työssä sydämen systolista toimintaa parantava vaikutus. Tämä näkyi tendenssinä parantaa ejektiofraktioita ja vasemman kammion supistuvuusosuuksia. Sydämen diastoliseen toimintaan ei kummallakaan lääkeaineella ollut merkittävää vaikutusta. Diastolista toimintaa arvioitiin isovolumetrisen relaksaatioajan muutoksilla. Sydämen hypertrofian kehittymiseen ei kummallakaan lääkeaineella ollut merkittävää vaikutusta. Eläinmallin todettiin mallintavan hyvin sydämen hypetrofiaa ihmisellä, mutta ei niinkään sydämen vajaatoimintaa.

Migration-Development Nexus in the Malawian Health Sector: European Union Blue Card – circular migration for development?

The European Union has agreed on implementing the Policy Coherence for Development (PCD) principle in all policy sectors that are likely to have a direct impact on developing countries. This is in order to take account of and support the EU development cooperation objectives and the achievement of the internationally agreed Millennium Development Goals. The common EU migration policy and the newly introduced EU Blue Card directive present an example of the implementation of the principle in practice: the directive is not only designed to respond to the occurring EU labour demand by attracting highly skilled third-country professionals, but is also intended to contribute to the development objectives of the migrant-sending developing countries, primarily through the tool of circular migration and the consequent skills transfers. My objective in this study is to assess such twofold role of the EU Blue Card and to explore the idea that migration could be harnessed for the benefit of development in conformity with the notion that the two form a positive nexus. Seeing that the EU Blue Card fails to differentiate the most vulnerable countries and sectors from those that are in a better position to take advantage of the global migration flows, the developmental consequences of the directive must be accounted for even in the most severe settings. Accordingly, my intention is to question whether circular migration, as claimed, could address the problem of brain drain in the Malawian health sector, which has witnessed an excessive outflow of its professionals to the UK during the past decade. In order to assess the applicability, likelihood and relevance of circular migration and consequent skills transfers for development in the Malawian context, a field study of a total of 23 interviews with local health professionals was carried out in autumn 2010. The selected approach not only allows me to introduce a developing country perspective to the on-going discussion at the EU level, but also enables me to assess the development dimension of the EU Blue Card and the intended PCD principle through a local lens. Thus these interviews and local viewpoints are at the very heart of this study. Based on my findings from the field, the propensity of the EU Blue Card to result in circular migration and to address the persisting South-North migratory flows as well as the relevance of skills transfers can be called to question. This is as due to the bias in its twofold role the directive overlooks the importance of the sending country circumstances, which are known to determine any developmental outcomes of migration, and assumes that circular migration alone could bring about immediate benefits. Without initial emphasis on local conditions, however, positive outcomes for vulnerable countries such as Malawi are ever more distant. Indeed it seems as if the EU internal interests in migration policy forbid the fulfilment of the PCD principle and diminish the attempt to harness migration for development to bare rhetoric.

Accretion of Chaplygin gas upon black holes: formation of faster outflowing winds

We study the accretion of modified Chaplygin gas upon different types of black holes. Modified Chaplygin gas is one of the best candidates for a combined model of dark matter and dark energy. In addition, from a field theoretical point of view the modified Chaplygin gas model is equivalent to that of a scalar field having a self-interacting potential. We formulate the equations related to both spherical accretion and disc accretion, and respective winds. The corresponding numerical solutions of the flow, particularly of velocity, are presented and analysed. We show that the accretion-wind system of modified Chaplygin gas dramatically alters the wind solutions, producing faster winds, upon changes in physical parameters, while accretion solutions qualitatively remain unaffected. This implies that modified Chaplygin gas is more prone to produce outflow which is the natural consequence of the dark energy into the system.

Extended Muskingum method for flood routing

Routing of floods is essential to control the flood flow at the flood control station such that it is within the specified safe limit. In this paper, the applicability of the extended Muskingum method is examined for routing of floods for a case study of Hirakud reservoir, Mahanadi river basin, India. The inflows to the flood control station are of two types-one controllable which comprises of reservoir releases for power and spill and the other is uncontrollable which comprises of inflow from lower tributaries and intermediate catchment between the reservoir and the flood control station. Muskingum model is improved to incorporate multiple sources of inflows and single outflow to route the flood in the reach. Instead of time lag and prismoidal flow parameters, suitable coefficients for various types of inflows were derived using Linear Programming. Presently, the decisions about operation of gates of Hirakud dam are being taken once in 12 h during floods. However, four time intervals of 24, 18, 12 and 6 h are examined to test the sensitivity of the routing time interval on the computed flood flow at the flood control station. It is observed that mean relative error decreases with decrease in routing interval both for calibration and testing phase. It is concluded that the extended Muskingum method can be explored for similar reservoir configurations such as Hirakud reservoir with suitable modifications. (C) 2010 International Association of Hydro-environment Engineering and Research. Asia Pacific Division. Published by Elsevier By. All rights reserved.

A summer monsoon pump to keep the Bay of Bengal salty

The Bay of Bengal receives a large influx of freshwater from precipitation and river discharge. Outflow of excess freshwater and inflow of saltier water is required to prevent the bay from freshening. Relatively fresh water flows out of the bay along its boundaries and inflow of saltier water occurs via the Summer Monsoon Current (SMC), which flows eastward from the Arabian Sea into the bay. This saltier water, however, slides under the lighter surface water of the bay. Maintaining the salt balance of the bay therefore demands upward mixing of this saltier, subsurface water. Here, we show that an efficient mechanism for this mixing is provided by upward pumping of saltier water in several bursts during the summer monsoon along the meandering path of the SMC. Advection by currents can then take this saltier water into the rest of the basin, allowing the bay to stay salty despite a large net freshwater input.

On the mass flow rate from silos with lateral exit holes

The mass flow rate, (m) over dot, associated with the lateral outflow of dry, cohesionless granular material through circular orifices of diameter D made in vertical walls of silos was measured experimentally in order to determine also the influence of the wall thickness of the silo, w. Geometrical arguments, based on the outflow happening, are given in order to have a general correlation for (m) over dot embracing both quantities, D and w. The angle of repose appears to be an important characterization factor in these kinds of flows.

Modeling the vulnerability of an urban groundwater system due to the combined impacts of climate change and management scenarios

Climate change impact on a groundwater-dependent small urban town has been investigated in the semiarid hard rock aquifer in southern India. A distributed groundwater model was used to simulate the groundwater levels in the study region for the projected future rainfall (2012-32) obtained from a general circulation model (GCM) to estimate the impacts of climate change and management practices on groundwater system. Management practices were based on the human-induced changes on the urban infrastructure such as reduced recharge from the lakes, reduced recharge from water and wastewater utility due to an operational and functioning underground drainage system, and additional water extracted by the water utility for domestic purposes. An assessment of impacts on the groundwater levels was carried out by calibrating a groundwater model using comprehensive data gathered during the period 2008-11 and then simulating the future groundwater level changes using rainfall from six GCMs Institute of Numerical Mathematics Coupled Model, version 3.0 (INM-CM. 3.0); L'Institut Pierre-Simon Laplace Coupled Model, version 4 (IPSL-CM4); Model for Interdisciplinary Research on Climate, version 3.2 (MIROC3.2); ECHAM and the global Hamburg Ocean Primitive Equation (ECHO-G); Hadley Centre Coupled Model, version 3 (HadCM3); and Hadley Centre Global Environment Model, version 1 (HadGEM1)] that were found to show good correlation to the historical rainfall in the study area. The model results for the present condition indicate that the annual average discharge (sum of pumping and natural groundwater outflow) was marginally or moderately higher at various locations than the recharge and further the recharge is aided from the recharge from the lakes. Model simulations showed that groundwater levels were vulnerable to the GCM rainfall and a scenario of moderate reduction in recharge from lakes. Hence, it is important to sustain the induced recharge from lakes by ensuring that sufficient runoff water flows to these lakes.

Influence of Spatial Variation of Hydraulic Conductivity of Municipal Solid Waste on Performance of Bioreactor Landfill

The current study analyzes the leachate distribution in the Orchard Hills Landfill, Davis Junction, Illinois, using a two-phase flow model to assess the influence of variability in hydraulic conductivity on the effectiveness of the existing leachate recirculation system and its operations through reliability analysis. Numerical modeling, using finite-difference code, is performed with due consideration to the spatial variation of hydraulic conductivity of the municipal solid waste (MSW). The inhomogeneous and anisotropic waste condition is assumed because it is a more realistic representation of the MSW. For the reliability analysis, the landfill is divided into 10 MSW layers with different mean values of vertical and horizontal hydraulic conductivities (decreasing from top to bottom), and the parametric study is performed by taking the coefficients of variation (COVs) as 50, 100, 150, and 200%. Monte Carlo simulations are performed to obtain statistical information (mean and COV) of output parameters of the (1) wetted area of the MSW, (2) maximum induced pore pressure, and (3) leachate outflow. The results of the reliability analysis are used to determine the influence of hydraulic conductivity on the effectiveness of the leachate recirculation and are discussed in the light of a deterministic approach. The study is useful in understanding the efficiency of the leachate recirculation system. (C) 2013 American Society of Civil Engineers.

Nucleosynthesis in the outflows associated with accretion disks of type II collapsars

We investigate nucleosynthesis inside the outflows from gamma-ray burst (GRB) accretion disks formed by the Type II collapsars. In these collapsars, massive stars undergo core collapse to form a proto-neutron star initially, and a mild supernova (SN) explosion is driven. The SN ejecta lack momentum, and subsequently this newly formed neutron star gets transformed to a stellar mass black hole via massive fallback. The hydrodynamics and the nucleosynthesis in these accretion disks have been studied extensively in the past. Several heavy elements are synthesized in the disk, and much of these heavy elements are ejected from the disk via winds and outflows. We study nucleosynthesis in the outflows launched from these disks by using an adiabatic, spherically expanding outflow model, to understand which of these elements thus synthesized in the disk survive in the outflow. While studying this, we find that many new elements like isotopes of titanium, copper, zinc, etc., are present in the outflows. Ni-56 is abundantly synthesized in most of the cases in the outflow, which implies that the outflows from these disks in a majority of cases will lead to an observable SN explosion. It is mainly present when outflow is considered from the He-rich, Ni-56/Fe-54-rich zones of the disks. However, outflow from the Si-rich zone of the disk remains rich in silicon. Although emission lines of many of these heavy elements have been observed in the X-ray afterglows of several GRBs by Chandra, BeppoSAX, XMM-Newton, etc., Swift seems to have not yet detected these lines.

Influence of exhaust gas heating and L/D ratios on the discharge efficiencies for an activated carbon natural gas storage system

A transient 2D axi-symmetric and lumped parameter (LP) model with constant outflow conditions have been developed to study the discharge capacity of an activated carbon bed. The predicted discharge times and variations in bed pressure and temperature are in good agreement with experimental results obtained from a 1.82 l adsorbed natural gas (ANG) storage system. Under ambient air conditions, a maximum temperature drop of 29.5 K and 45.5 K are predicted at the bed center for discharge rates of 1.0 l min(-1) and 5.0 l min(-1) respectively. The corresponding discharge efficiencies are 77% and 71.5% respectively with discharge efficiencies improving with decreasing outflow rates. Increasing the LID ratio from 1.9 to 7.8 had only a marginal increase in the discharge efficiency. Forced convection (exhaust gas) heating had a significant effect on the discharge efficiency, leading to efficiencies as high as 92.8% at a discharge of 1.0 l min(-1) and 88.7% at 5 l min(-1). Our study shows that the LP model can be reliably used to obtain discharge times due to the uniform pressure distributions in the bed. Temperature predictions with the LP model were more accurate at ambient conditions and higher discharge rates, due to greater uniformity in bed temperatures. For the low thermal conductivity carbon porous beds, our study shows that exhaust gas heating can be used as an effective and convenient strategy to improve the discharge characteristics and performance of an ANG system. (C) 2013 Elsevier Ltd. All rights reserved.

The generalized Onsager model for a binary gas mixture

The Onsager model for the secondary flow field in a high-speed rotating cylinder is extended to incorporate the difference in mass of the two species in a binary gas mixture. The base flow is an isothermal solid-body rotation in which there is a balance between the radial pressure gradient and the centrifugal force density for each species. Explicit expressions for the radial variation of the pressure, mass/mole fractions, and from these the radial variation of the viscosity, thermal conductivity and diffusion coefficient, are derived, and these are used in the computation of the secondary flow. For the secondary flow, the mass, momentum and energy equations in axisymmetric coordinates are expanded in an asymptotic series in a parameter epsilon = (Delta m/m(av)), where Delta m is the difference in the molecular masses of the two species, and the average molecular mass m(av) is defined as m(av) = (rho(w1)m(1) + rho(w2)m(2))/rho(w), where rho(w1) and rho(w2) are the mass densities of the two species at the wall, and rho(w) = rho(w1) + rho(w2). The equation for the master potential and the boundary conditions are derived correct to O(epsilon(2)). The leading-order equation for the master potential contains a self-adjoint sixth-order operator in the radial direction, which is different from the generalized Onsager model (Pradhan & Kumaran, J. Fluid Mech., vol. 686, 2011, pp. 109-159), since the species mass difference is included in the computation of the density, viscosity and thermal conductivity in the base state. This is solved, subject to boundary conditions, to obtain the leading approximation for the secondary flow, followed by a solution of the diffusion equation for the leading correction to the species mole fractions. The O(epsilon) and O(epsilon(2)) equations contain inhomogeneous terms that depend on the lower-order solutions, and these are solved in a hierarchical manner to obtain the O(epsilon) and O(epsilon(2)) corrections to the master potential. A similar hierarchical procedure is used for the Carrier-Maslen model for the end-cap secondary flow. The results of the Onsager hierarchy, up to O(epsilon(2)), are compared with the results of direct simulation Monte Carlo simulations for a binary hard-sphere gas mixture for secondary flow due to a wall temperature gradient, inflow/outflow of gas along the axis, as well as mass and momentum sources in the flow. There is excellent agreement between the solutions for the secondary flow correct to O(epsilon(2)) and the simulations, to within 15 %, even at a Reynolds number as low as 100, and length/diameter ratio as low as 2, for a low stratification parameter A of 0.707, and when the secondary flow velocity is as high as 0.2 times the maximum base flow velocity, and the ratio 2 Delta m/(m(1) + m(2)) is as high as 0.5. Here, the Reynolds number Re = rho(w)Omega R-2/mu, the stratification parameter A = root m Omega R-2(2)/(2k(B)T), R and Omega are the cylinder radius and angular velocity, m is the molecular mass, rho(w) is the wall density, mu is the viscosity and T is the temperature. The leading-order solutions do capture the qualitative trends, but are not in quantitative agreement.

Long way to go: how outflows from large galaxies propagate through the hot halo gas

Using hydrodynamic simulations, we study the mass-loss due to supernova-driven outflows from Milky Way type disc galaxies, paying particular attention to the effect of the extended hot halo gas. We find that the total mass-loss at inner radii scales roughly linearly with total mass of stars formed, and that the mass loading factor at the virial radius can be several times its value at inner radii because of the swept up hot halo gas. The temperature distribution of the outflowing material in the inner region (similar to 10 kpc) is bimodal in nature, peaking at 10(5) K and 10(6.5) K, responsible for optical and X-ray emission, respectively. The contribution of cold/warm gas with temperature <= 10(5.5) K to the outflow rate within 10 kpc is approximate to 0.3-0.5. The warm mass loading factor, eta(3e5) (T <= 3 x 10(5) K) is related to the mass loading factor at the virial radius (eta(v)) as eta(v) approximate to 25 eta(3e5) (SFR/M-circle dot yr(-1))(-0.15) for a baryon fraction of 0.1 and a starburst period of 50 Myr. We also discuss the effect of multiple bursts that are separated by both short and long periods. The outflow speed at the virial radius is close to the sound speed in the hot halo, less than or similar to 200 km s(-1). We identify two `sequences' of outflowing cold gas at small scales: a fast (approximate to 500 km s(-1)) sequence, driven by the unshocked free-wind; and a slow sequence (approximate to +/- 100 km s(-1)) at the conical interface of the superwind and the hot halo.

COOL CORE CYCLES: COLD GAS AND AGN JET FEEDBACK IN CLUSTER CORES

Using high-resolution 3D and 2D (axisymmetric) hydrodynamic simulations in spherical geometry, we study the evolution of cool cluster cores heated by feedback-driven bipolar active galactic nuclei (AGNs) jets. Condensation of cold gas, and the consequent enhanced accretion, is required for AGN feedback to balance radiative cooling with reasonable efficiencies, and to match the observed cool core properties. A feedback efficiency (mechanical luminosity approximate to epsilon(M) over dot(acc)c(2); where (M) over dot(acc). is the mass accretion rate at 1 kpc) as small as 6 x 10(-5) is sufficient to reduce the cooling/accretion rate by similar to 10 compared to a pure cooling flow in clusters (with M-200 less than or similar to 7 x 10(14) M-circle dot). This value is much smaller compared to the ones considered earlier, and is consistent with the jet efficiency and the fact that only a small fraction of gas at 1 kpc is accreted onto the supermassive black hole (SMBH). The feedback efficiency in earlier works was so high that the cluster core reached equilibrium in a hot state without much precipitation, unlike what is observed in cool-core clusters. We find hysteresis cycles in all our simulations with cold mode feedback: condensation of cold gas when the ratio of the cooling-time to the free-fall time (t(cool)/t(ff)) is less than or similar to 10 leads to a sudden enhancement in the accretion rate; a large accretion rate causes strong jets and overheating of the hot intracluster medium such that t(cool)/t(ff) > 10; further condensation of cold gas is suppressed and the accretion rate falls, leading to slow cooling of the core and condensation of cold gas, restarting the cycle. Therefore, there is a spread in core properties, such as the jet power, accretion rate, for the same value of core entropy t(cool)/t(ff). A smaller number of cycles is observed for higher efficiencies and for lower mass halos because the core is overheated to a longer cooling time. The 3D simulations show the formation of a few-kpc scale, rotationally supported, massive (similar to 10(11) M-circle dot) cold gas torus. Since the torus gas is not accreted onto the SMBH, it is largely decoupled from the feedback cycle. The radially dominant cold gas (T < 5 x 10(4) K; vertical bar v(r)vertical bar >vertical bar v(phi vertical bar)) consists of fast cold gas uplifted by AGN jets and freely infalling cold gas condensing out of the core. The radially dominant cold gas extends out to 25 kpc for the fiducial run (halo mass 7 x 10(14) M-circle dot and feedback efficiency 6 x 10(-5)), with the average mass inflow rate dominating the outflow rate by a factor of approximate to 2. We compare our simulation results with recent observations.

Diffusive Wave Solutions for Open Channel Flows with Uniform and Concentrated Lateral Inflow

The diffusive wave equation with inhomogeneous terms representing hydraulics with uniform or concentrated lateral inflow intoa river is theoretically investigated in the current paper. All the solutions have been systematically expressed in a unified form interms of response function or so called K-function. The integration of K-function obtained by using Laplace transform becomesS-function, which is examined in detail to improve the understanding of flood routing characters. The backwater effects usuallyresulting in the discharge reductions and water surface elevations upstream due to both the downstream boundary and lateral infloware analyzed. With a pulse discharge in upstream boundary inflow, downstream boundary outflow and lateral inflow respectively,hydrographs of a channel are routed by using the S-functions. Moreover, the comparisons of hydrographs in infinite, semi-infiniteand finite channels are pursued to exhibit the different backwater effects due to a concentrated lateral inflow for various channeltypes.

The influence of stacks on flow patterns and stratification associated with natural ventilation

We investigate the steady state natural ventilation of an enclosed space in which vent A, located at height hA above the floor, is connected to a vertical stack with a termination at height H, while the second vent, B, at height hB above the floor, connects directly to the exterior. We first examine the flow regimes which develop with a distributed source of heating at the base of the space. If hBhB>hA, then two different flow regimes may develop. Either (i) there is inflow through vent B and outflow through vent A, or (ii) the flow reverses, with inflow down the stack into vent A and outflow through vent B. With inflow through vent A, the internal temperature and ventilation rate depend on the relative height of the two vents, A and B, while with inflow through vent B, they depend on the height of vent B relative to the height of the termination of the stack H. With a point source of heating, a similar transition occurs, with a unique flow regime when vent B is lower than vent A, and two possible regimes with vent B higher than vent A. In general, with a point source of buoyancy, each steady state is characterised by a two-layer density stratification. Depending on the relative heights of the two vents, in the case of outflow through vent A connected to the stack, the interface between these layers may lie above, at the same level as or below vent A, leading to discharge of either pure upper layer, a mixture of upper and lower layer, or pure lower layer fluid. In the case of inflow through vent A connected to the stack, the interface always lies below the outflow vent B. Also, in this case, if the inflow vent A lies above the interface, then the lower layer becomes of intermediate density between the upper layer and the external fluid, whereas if the interface lies above the inflow vent A, then the lower layer is composed purely of external fluid. We develop expressions to predict the transitions between these flow regimes, in terms of the heights and areas of the two vents and the stack, and we successfully test these with new laboratory experiments. We conclude with a discussion of the implications of our results for real buildings.