Ethnic Minority Children’s Active Commuting to School and Association with Physical Activity and Pedestrian Safety Behaviors

Background: Children's active commuting to school, i.e. walking or cycling to school, was associated with greater moderate-to-vigorous physical activity, although studies among ethnic minorities are sparse. Objectives: Among a low-income, ethnic minority sample of fourth grade students from eight public schools, we examined (1) correlates of active commuting to school and (2) the relationship between active commuting to school and moderate-to-vigorous physical activity. Methods: We conducted a cross-sectional analysis of baseline measurements from a sample of participants (n=149) aged 9-12 years from a walk to school intervention study in Houston, Texas. The primary outcome was the weekly rate of active commuting to school. Daily moderate-to-vigorous physical activity, measured by accelerometers, was a secondary outcome. Child self-efficacy (alpha=0.75), parent self-efficacy (alpha=0.88), and parent outcome expectations (alpha=0.78) were independent variables. Participant characteristics (age, gender, race/ethnicity, distance from home to school, acculturation, and BMI percentile) were independent sociodemographic variables. We used mixed-model regression analyses to account for clustering by school and a stepwise procedure with backward elimination of non-significant interactions and covariates to identify significant moderators and predictors. School-level observations of student pedestrians were assessed and compared using chi-square tests of independence. Results: Among our sample, which was 61.7% Latino, the overall rate of active commuting to school was 43%. In the mixed model for active commuting to school, parent self-efficacy (std. beta = 0.18, p=0.018) and age (std. beta = 0.18, p=0.018) were positively related. Latino students had lower rates of active commuting to school than non-Latinos ( 16.5%, p=0.040). Distance from home to school was inversely related to active commuting to school (std. beta = 0.29, p<0.001). In the mixed model for moderate-to-vigorous physical activity, active commuting to school was positively associated (std. beta = 0.31, p <0.001). Among the Latino subsample, child acculturation was negatively associated with active commuting to school (std. beta = -0.23, p=0.01). With regard to school-level pedestrian safety observations, 37% of students stopped at the curb and 2.6% looked left-right-left before crossing the street. Conclusion: Although still below national goals, the rate of active commuting was relatively high, while the rate of some pedestrian safety behaviors was low among this low-income, ethnic minority population. Programs and policies to encourage safe active commuting to school are warranted and should consider the influence of parents, acculturation, and ethnicity.

Deep gray matter atrophy in multiple sclerosis: a tensor based morphometry.

Tensor based morphometry (TBM) was applied to determine the atrophy of deep gray matter (DGM) structures in 88 relapsing multiple sclerosis (MS) patients. For group analysis of atrophy, an unbiased atlas was constructed from 20 normal brains. The MS brain images were co-registered with the unbiased atlas using a symmetric inverse consistent nonlinear registration. These studies demonstrate significant atrophy of thalamus, caudate nucleus, and putamen even at a modest clinical disability, as assessed by the expanded disability status score (EDSS). A significant correlation between atrophy and EDSS was observed for different DGM structures: (thalamus: r=-0.51, p=3.85 x 10(-7); caudate nucleus: r=-0.43, p=2.35 x 10(-5); putamen: r=-0.36, p=6.12 x 10(-6)). Atrophy of these structures also correlated with 1) T2 hyperintense lesion volumes (thalamus: r=-0.56, p=9.96 x 10(-9); caudate nucleus: r=-0.31, p=3.10 x 10(-3); putamen: r=-0.50, p=6.06 x 10(-7)), 2) T1 hypointense lesion volumes (thalamus: r=-0.61, p=2.29 x 10(-10); caudate nucleus: r=-0.35, p=9.51 x 10(-4); putamen: r=-0.43, p=3.51 x 10(-5)), and 3) normalized CSF volume (thalamus: r=-0.66, p=3.55 x 10(-12); caudate nucleus: r=-0.52, p=2.31 x 10(-7), and putamen: r=-0.66, r=2.13 x 10(-12)). More severe atrophy was observed mainly in thalamus at higher EDSS. These studies appear to suggest a link between the white matter damage and DGM atrophy in MS.

The effect of acute exercise and psychosocial stress on fine motor skills and testosterone concentration in the saliva of high school students

Little is known about the influence of different stressors on fine motor skills, the concentration of testosterone (T), and their interaction in adolescents. Therefore, 62 high school students aged 14–15 years were randomly assigned to two experimental groups (exercise, psychosocial stress) and a control group. Exercise stress was induced at 65–75% of the maximum heart rate by running for 15 minutes (n = 24). Psychosocial stress was generated by an intelligence test (HAWIK- IV), which was uncontrollable and characterized by social-evaluative-threat to the students (n=21). The control group followed was part of a regular school lesson with the same duration (n = 28). Saliva was collected after a normal school lesson (pre-test) as well as after the intervention/control period (post-test) and was analyzed for testosterone. Fine motor skills were assessed pre- and post-intervention using a manual dexterity test (Flower Trail) from the Movement Assessment Battery for Children-2. A repeated measure ANCOVA including gender as a covariate revealed a significant group by test interaction, indicating an increase in manual dexterity only for the psychosocial stress group. Correlation analysis of all students shows that the change of testosterone from pre- to post-test was directly linked (r = 2.31, p = .01) to the changes in manual dexterity performance. Participants showing high increases in testosterone from pre- to post-test made fewer mistakes in the fine motor skills task. Findings suggest that manual dexterity increases when psychosocial stress is induced and that improvement of manual dexterity performance corresponds with the increase of testosterone.

Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC

Purpose We hypothesized that reduced arousability (Richmond Agitation Sedation Scale, RASS, scores −2 to −3) for any reason during delirium assessment increases the apparent prevalence of delirium in intensive care patients. To test this hypothesis, we assessed delirium using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) in intensive care patients during sedation stops, and related the findings to the level of sedation, as assessed with RASS score. Methods We assessed delirium in 80 patients with ICU stay longer than 48 h using CAM-ICU and ICDSC during daily sedation stops. Sedation was assessed using RASS. The effect of including patients with a RASS of −2 and −3 during sedation stop (“light to moderate sedation”, eye contact less than 10 s or not at all, respectively) on prevalence of delirium was analyzed. Results A total of 467 patient days were assessed. The proportion of CAM-ICU-positive evaluations decreased from 53 to 31 % (p < 0.001) if assessments from patients at RASS −2/−3 (22 % of all assessments) were excluded. Similarly, the number of positive ICDSC results decreased from 51 to 29 % (p < 0.001). Conclusions Sedation per se can result in positive items of both CAM-ICU and ICDSC, and therefore in a diagnosis of delirium. Consequently, apparent prevalence of delirium is dependent on how a depressed level of consciousness after sedation stop is interpreted (delirium vs persisting sedation). We suggest that any reports on delirium using these assessment tools should be stratified for a sedation score during the assessment.

Predictors of thromboprophylaxis in hospitalised medical patients. Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE).

Both, underuse and overuse of thromboprophylaxis in hospitalised medical patients is common. We aimed to explore clinical factors associated with the use of pharmacological or mechanical thromboprophylaxis in acutely ill medical patients at high (Geneva Risk Score ≥ 3 points) vs low (Geneva Risk Score < 3 points) risk of venous thromboembolism. Overall, 1,478 hospitalised medical patients from eight large Swiss hospitals were enrolled in the prospective Explicit ASsessment of Thromboembolic RIsk and Prophylaxis for Medical PATients in SwitzErland (ESTIMATE) cohort study. The study is registered on ClinicalTrials.gov, number NCT01277536. Thromboprophylaxis increased stepwise with increasing Geneva Risk Score (p< 0.001). Among the 962 high-risk patients, 366 (38 %) received no thromboprophylaxis; cancer-associated thrombocytopenia (OR 4.78, 95 % CI 2.75-8.31, p< 0.001), active bleeding on admission (OR 2.88, 95 % CI 1.69-4.92, p< 0.001), and thrombocytopenia without cancer (OR 2.54, 95 % CI 1.31-4.95, p=0.006) were independently associated with the absence of prophylaxis. The use of thromboprophylaxis declined with increasing severity of thrombocytopenia (p=0.001). Among the 516 low-risk patients, 245 (48 %) received thromboprophylaxis; none of the investigated clinical factors predicted its use. In conclusion, in acutely ill medical patients, bleeding and thrombocytopenia were the most important factors for the absence of thromboprophylaxis among high-risk patients. The use of thromboprophylaxis among low-risk patients was inconsistent, without clearly identifiable predictors, and should be addressed in further research.

Impact of development of job control and task-related stressors on resigned job attitude.

With more experience in the labor market, some job characteristics increase, some decrease. For example, among young employees who just entered the labor market, job control may initially be low but increase with more routine and experience. Job control is a job resource that is valued in itself and is positively associated with job satisfaction; but job control also helps dealing with stressors at work. There is little research on correlated changes, but the existing evidence suggests a joint development over time. However, even less is known about the relevance of such changes for employees. Usually, research tends to use mean levels to predict mean levels in outcomes but development in job control and stressors may be as relevant for job satisfaction as having a certain level in those job characteristics. Job satisfaction typically is regarded as a positive attitude towards one’s work. What has received less attention is that some employees may lower their expectations if their job situation does not reflect their needs, resulting in a resigned attitude towards one’s job. The present study investigates the development of job control and task-related stressors over ten years and tests the predictive value of changes in job control and task-related stressors for resigned attitude towards one’s job. We used data from a Swiss panel study (N=356) ranging over ten years. Job control, task-related stressors (an index consisting of time pressure, concentration demands, performance constraints, interruptions, and uncertainty about tasks), and resigned attitude towards one’s job were assessed in 1998, 1999, 2001, and 2008. Latent growth modeling revealed that growth rates of job control and task-related stressors were not correlated with one another. We predicted resigned attitude towards one’s job in 2008 a) by initial levels, and b) by changes in job control and stressors, controlling for resigned attitude in 1998. There was some prediction by initial levels (job control: β = -.15, p < .05; task-related stressors: β = .12, p = .06). However, as expected, changes in control and stressors predicted resigned attitude much better, with β = -.37, p < .001, for changes in job control, and β = .31, p < .001, for changes in task-related stressors. Our data confirm the importance of having low levels of task-related stressors and higher levels of job control for job attitudes. However, development in these job characteristics seems even more important than initial levels.

Stress-induced modulation of NF-κB activation, inflammation-associated gene expression, and cytokine levels in blood of healthy men

Acute psychosocial stress stimulates transient increases in circulating pro-inflammatory plasma cytokines, but little is known about stress effects on anti-inflammatory cytokines or underlying mechanisms. We investigated the stress kinetics and interrelations of pro- and anti-inflammatory measures on the transcriptional and protein level. Forty-five healthy men were randomly assigned to either a stress or control group. While the stress group underwent an acute psychosocial stress task, the second group participated in a non-stress control condition. We repeatedly measured before and up to 120min after stress DNA binding activity of the pro-inflammatory transcription factor NF-κB (NF-κB-BA) in peripheral blood mononuclear cells, whole-blood mRNA levels of NF-κB, its inhibitor IκBα, and of the pro-inflammatory cytokines interleukin (IL)-1ß and IL-6, and the anti-inflammatory cytokine IL-10. We also repeatedly measured plasma levels of IL-1ß, IL-6, and IL-10. Compared to non-stress, acute stress induced significant and rapid increases in NF-κB-BA and delayed increases in plasma IL-6 and mRNA of IL-1ß, IL-6, and IκBα (p's<.045). In the stress group, significant increases over time were also observed for NF-κB mRNA and plasma IL-1ß and IL-10 (p's<.055). NF-κB-BA correlated significantly with mRNA of IL-1β (r=.52, p=.002), NF-κB (r=.48, p=.004), and IκBα (r=.42, p=.013), and marginally with IL-6 mRNA (r=.31, p=.11). Plasma cytokines did not relate to NF-κB-BA or mRNA levels of the respective cytokines. Our data suggest that stress induces increases in NF-κB-BA that relate to subsequent mRNA expression of pro-inflammatory, but not anti-inflammatory cytokines, and of regulatory-cytoplasmic-proteins. The stress-induced increases in plasma cytokines do not seem to derive from de novo synthesis in circulating blood cells.

Exercise efficiency relates with mitochondrial content and function in older adults

Chronic aerobic exercise has been shown to increase exercise efficiency, thus allowing less energy expenditure for a similar amount of work. The extent to which skeletal muscle mitochondria play a role in this is not fully understood, particularly in an elderly population. The purpose of this study was to determine the relationship of exercise efficiency with mitochondrial content and function. We hypothesized that the greater the mitochondrial content and/or function, the greater would be the efficiencies. Thirty-eight sedentary (S, n = 23, 10F/13M) or athletic (A, n = 15, 6F/9M) older adults (66.8 ± 0.8 years) participated in this cross sectional study. V˙O2peak was measured with a cycle ergometer graded exercise protocol (GXT). Gross efficiency (GE, %) and net efficiency (NE, %) were estimated during a 1-h submaximal test (55% V˙O2peak). Delta efficiency (DE, %) was calculated from the GXT. Mitochondrial function was measured as ATPmax (mmol/L/s) during a PCr recovery protocol with (31)P-MR spectroscopy. Muscle biopsies were acquired for determination of mitochondrial volume density (MitoVd, %). Efficiencies were 17% (GE), 14% (NE), and 16% (DE) higher in A than S. MitoVD was 29% higher in A and ATPmax was 24% higher in A than in S. All efficiencies positively correlated with both ATPmax and MitoVd. Chronically trained older individuals had greater mitochondrial content and function, as well as greater exercise efficiencies. GE, NE, and DE were related to both mitochondrial content and function. This suggests a possible role of mitochondria in improving exercise efficiency in elderly athletic populations and allowing conservation of energy at moderate workloads.

Colonization with resistant microorganisms in patients transferred from abroad: who needs to be screened?

BACKGROUND While multi-drug resistant organisms (MDRO) are a global phenomenon, there are significant regional differences in terms of prevalence. Traveling to countries with a high MDRO prevalence increases the risk of acquiring such an organism. In this study we determined risk factors for MDRO colonization among patients who returned from a healthcare system in a high-prevalence area (so-called transfer patients). Factors predicting colonization could serve as screening criteria to better target those at highest risk. METHODS This screening study included adult patients who had been exposed to a healthcare system abroad or in a high-prevalence region in Switzerland over the past six months and presented to our 950-bed tertiary care hospital between January 1, 2012 and December 31, 2013, a 24-month period. Laboratory screening tests focused on Gram-negative MDROs and methicillin-resistant Staphylococcus aureus (MRSA). RESULTS A total of 235 transfer patients were screened and analyzed, of which 43 (18 %) were positive for an MDRO. Most of them yielded Gram-negative bacteria (42; 98 %), with only a single screening revealing MRSA (2 %); three screenings showed a combination of Gram-negative bacteria and MRSA. For the risk factor analysis we focused on the 42 Gram-negative MDROs. Most of them were ESBL-producing Escherichia coli and Klebsiella pneumoniae while only two were carbapenemase producers. In univariate analysis, factors associated with screening positivity were hospitalization outside of Europe (p < 0.001), surgical procedure in a hospital abroad (p = 0.007), and - on admission to our hospital - active infection (p = 0.002), antibiotic treatment (p = 0.014) and presence of skin lesions (p = 0.001). Only hospitalization outside of Europe (Odds Ratio, OR 3.2 (95 % CI 1.5- 6.8)) and active infection on admission (OR 2.7 (95 % CI 1.07- 6.6)) remained as independent predictors of Gram-negative MDRO colonization. CONCLUSION Our data suggest that a large proportion of patients (i.e., 82 %) transferred to Switzerland from hospitals in high MDRO prevalence areas are unnecessarily screened for MDRO colonization. Basing our screening strategy on certain criteria (such as presence of skin lesions, active infection, antibiotic treatment, history of a surgical procedure abroad and hospitalization outside of Europe) promises to be a better targeted and more cost-effective strategy.

Effects of (un)predictable whole body vibrations on visual performance

Over recent years, it has repeatedly been shown that optimal gaze strategies enhance motor control (e.g., Foulsham, 2015). However, little is known, whether, vice versa, visual performance can be improved by optimized motor control. Consequently, in two studies, we investigated visual performance as a function of motor control strategies and task parameters, respectively. In Experiment 1, 72 participants were tested on visual acuity (Landolt) and contrast sensitivity (Grating), while standing in two different postures (upright vs. squat) on a ZEPTOR-platform that vibrated at four different frequencies (0, 4, 8, 12 Hz). After each test, perceived exertion (Borg) was assessed. Significant interactions were revealed for both tests, Landolt: F(3,213)=13.25, p<.01, ηp2=.16, Grating: F(3,213)=4.27, p<.01, ηp2=.06, elucidating a larger loss of acuity/contrast sensitivity with increasing frequencies for the upright compared with the squat posture. For perceived exertion, however, a diametrical interaction for frequency was found for acuity, F(3,213)=7.45, p<.01, ηp2=.09, and contrast sensitivity, F(3,213)=7.08, p < .01, ηp2=.09, substantiating that the impaired visual performance cannot be attributed to exertion. Consequently, the squat posture could permit better head and, hence, gaze stabilization. In Experiment 2, 64 participants performed the same tests while standing in a squat position on a ski-simulator, which vibrated with two different frequencies (2.4, 3.6 Hz) and amplitudes (50, 100 mm) in a predictable or unpredictable manner. Control strategies were identified by tracking segmental motion, which allows to derive damping characteristics. Considerable main effects were found for frequency, all F’s(1,52)>10.31, all p’s<.01, all ηp2’s>.16, as well as, in the acuity test, for predictability, F(1,52)=10.31, p<.01, ηp2=.17, and by tendency for amplitude, F(1,52)=3.53, p=.06, ηp2=.06. A significant correlation between the damping amplitude in the knee joint and the performance drop in visual acuity, r=-.97, p<.001, again points towards the importance of motor control strategies to maintain optimal visual performance.

Detection of muscle wasting in patients with chronic heart failure using C-terminal agrin fragment: results from the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF).

AIMS Skeletal muscle wasting affects 20% of patients with chronic heart failure and has serious implications for their activities of daily living. Assessment of muscle wasting is technically challenging. C-terminal agrin-fragment (CAF), a breakdown product of the synaptically located protein agrin, has shown early promise as biomarker of muscle wasting. We sought to investigate the diagnostic properties of CAF in muscle wasting among patients with heart failure. METHODS AND RESULTS We assessed serum CAF levels in 196 patients who participated in the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). Muscle wasting was identified using dual-energy X-ray absorptiometry (DEXA) in 38 patients (19.4%). Patients with muscle wasting demonstrated higher CAF values than those without (125.1 ± 59.5 pmol/L vs. 103.8 ± 42.9 pmol/L, P = 0.01). Using receiver operating characteristics (ROC), we calculated the optimal CAF value to identify patients with muscle wasting as >87.5 pmol/L, which had a sensitivity of 78.9% and a specificity of 43.7%. The area under the ROC curve was 0.63 (95% confidence interval 0.56-0.70). Using simple regression, we found that serum CAF was associated with handgrip (R = - 0.17, P = 0.03) and quadriceps strength (R = - 0.31, P < 0.0001), peak oxygen consumption (R = - 0.5, P < 0.0001), 6-min walk distance (R = - 0.32, P < 0.0001), and gait speed (R = - 0.2, P = 0.001), as well as with parameters of kidney and liver function, iron metabolism and storage. CONCLUSION CAF shows good sensitivity for the detection of skeletal muscle wasting in patients with heart failure. Its assessment may be useful to identify patients who should undergo additional testing, such as detailed body composition analysis. As no other biomarker is currently available, further investigation is warranted.

Platelet-rich concentrates differentially release growth factors and induce cell migration in vitro

BACKGROUND Platelet-rich concentrates are used as a source of growth factors to improve the healing process. The diverse preparation protocols and the gaps in knowledge of their biological properties complicate the interpretation of clinical results. QUESTIONS/PURPOSES In this study we aimed to (1) analyze the concentration and kinetics of growth factors released from leukocyte- and platelet-rich fibrin (L-PRF), leukocyte- and platelet-rich plasma (L-PRP), and natural blood clot during in vitro culture; (2) investigate the migration of mesenchymal stem cells (MSCs) and human umbilical vein endothelial cells (HUVECs) as a functional response to the factors released; and (3) uncover correlations between individual growth factors with the initial platelet/leukocyte counts or the induced cell migration. METHODS L-PRF, L-PRP, and natural blood clot prepared from 11 donors were cultured in vitro for 28 days and media supernatants collected after 8 hours and 1, 3, 7, 14, and 28 days. Released transforming growth factor β1 (TGF-β1), vascular endothelial growth factor (VEGF), insulin growth factor (IGF-1), platelet-derived growth factor AB (PDGF-AB), and interleukin-1β (IL-1β) were measured in the supernatants with enzyme-linked immunosorbent assay. Migration of MSC and HUVEC induced by the supernatants was evaluated in Boyden chambers. RESULTS More TGF-ß1 was released (mean ± SD in pg/mL of blood) from L-PRF (37,796 ± 5492) compared with L-PRP (23,738 ± 6848; p < 0.001) and blood clot (3739 ± 4690; p < 0.001), whereas more VEGF and IL-1ß were released from blood clot (1933 ± 704 and 2053 ± 908, respectively) compared with both L-PRP (642 ± 208; p < 0.001 and 273 ± 386; p < 0.001, respectively) and L-PRF (852 ± 376; p < 0.001 and 65 ± 56, p < 0.001, respectively). No differences were observed in IGF-1 and PDGF-AB released from any of the concentrates. TGF-β1 release peaked at Day 7 in L-PRF and at 8 hours and Day 7 in L-PRP and 8 hours and Day 14 in blood clot. In all concentrates, main release of VEGF occurred between 3 and 7 days and of IL-1β between Days 1 and 7. IGF-1 and PDGF-AB were released until Day 1 in L-PRP and blood clot, in contrast to sustained release over the first 3 days in L-PRF. The strongest migration of MSC occurred in response to L-PRF, and more HUVEC migration was seen in L-PRF and blood clot compared with L-PRP. TGF-β1 correlated with initial platelet counts in L-PRF (Pearson r = 0.66, p = 0.0273) and initial leukocyte counts in L-PRP (Pearson r = 0.83, p = 0.0016). A positive correlation of IL-1β on migration of MSC and HUVEC was revealed (Pearson r = 0.16, p = 0.0208; Pearson r = 0.31, p < 0.001). CONCLUSIONS In comparison to L-PRP, L-PRF had higher amounts of released TGF-β1, a long-term release of growth factors, and stronger induction of cell migration. Future preclinical studies should confirm these data in a defined injury model. CLINICAL RELEVANCE By characterizing the biologic properties of different platelet concentrates in vitro, we may gain a better understanding of their clinical effects and develop guidelines for specific future applications.

Prevention of Rebleeding From Esophageal Varices in Patients With Cirrhosis Receiving Small-Diameter Stents Versus Hemodynamically Controlled Medical Therapy

BACKGROUND & AIMS Patients with cirrhosis and variceal hemorrhage have a high risk of rebleeding. We performed a prospective randomized trial to compare the prevention of rebleeding in patients given a small-diameter covered stent vs those given hepatic venous pressure gradient (HVPG)-based medical therapy prophylaxis. METHODS We performed an open-label study of patients with cirrhosis (92% Child class A or B, 70% alcoholic) treated at 10 medical centers in Germany. Patients were assigned randomly more than 5 days after variceal hemorrhage to groups given a small covered transjugular intrahepatic portosystemic stent-shunt (TIPS) (8 mm; n = 90), or medical reduction of portal pressure (propranolol and isosorbide-5-mononitrate; n = 95). HVPG was determined at the time patients were assigned to groups (baseline) and 2 weeks later. In the medical group, patients with an adequate reduction in HVPG (responders) remained on the drugs whereas nonresponders underwent only variceal band ligation. The study was closed 10 months after the last patient was assigned to a group. The primary end point was variceal rebleeding. Survival, safety (adverse events), and quality of life (based on the Short Form-36 health survey) were secondary outcome measures. RESULTS A significantly smaller proportion of patients in the TIPS group had rebleeding within 2 years (7%) than in the medical group (26%) (P = .002). A slightly higher proportion of patients in the TIPS group experienced adverse events, including encephalopathy (18% vs 8% for medical treatment; P = .05). Rebleeding occurred in 6 of 23 patients (26%) receiving medical treatment before hemodynamic control was possible. Per-protocol analysis showed that rebleeding occurred in a smaller proportion of the 32 responders (18%) than in nonresponders who received variceal band ligation (31%) (P = .06). Fifteen patients from the medical group (16%) underwent TIPS placement during follow-up evaluation, mainly for refractory ascites. Survival time and quality of life did not differ between both randomized groups. CONCLUSIONS Placement of a small-diameter, covered TIPS was straightforward and prevented variceal rebleeding in patients with Child A or B cirrhosis more effectively than drugs, which often required step-by-step therapy. However, TIPS did not increase survival time or quality of life and produced slightly more adverse events. Clinical Trial no: ISRCTN 16334693.