***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Hemorrhage from esophageal varices in cirrhotics is a frequent event with high mortality in spite of therapy . Preventive sclerotherapy seems to be beneficial only if the patient 's bleeding risk is higher than 40 to 50 % a year . A series of 320 patients with esophageal varices without previous bleeding was studied prospect ively ; the varices were classified according to three widely used endoscopic classifications . During follow-up ( 6 to 36 months , average 14 months ) , hemorrhage occurred in 49 patients ( 15.3 % ) of whom 30 ( 61.2 % ) bled from varices ( 8.2 and 11.0 % at 12 and 24 months , respectively ) . At the same time intervals , mortality of the entire population studied was 18.0 and 23.8 % , respectively , of which one third was directly due to hemorrhage . With all three classifications , the higher the degree of bleeding risk , the greater the actual percentage of hemorrhages recorded ; however , it never reached 40 % a year . In predicting the bleeding event , Dagradi 's classification proved more sensitive than JRSPH or NIEC , but the latter classifications were more specific and assessed a higher predictive value for a positive test . Endoscopic observation probably needs integration with other methods if a reliable bleeding prediction is to be made Abstract Background : Endoscopic ligation ( EVL ) and endoscopic sclerotherapy ( EIS ) are both effective in the treatment of bleeding esophageal varices , but the efficacy of the two techniques in the prophylaxis of first variceal bleeding has not been investigated . The aim of this study was to investigate the frequency of first variceal bleeding , the recurrence of varices , and survival after treatment with the two techniques , as compared to a nontreated control group . Methods : A total of 157 patients with liver cirrhosis and advanced esophageal varices with no previous history of upper gastrointestinal bleeding were r and omly assigned to either an EIS group ( n= 55 ) , an EVL group ( n= 52 ) , or a nontreated control group ( n= 50 ) . After the eradication of esophageal varices in the EIS and in EVL groups and in all control patients , the endoscopic examination was performed at 3-month intervals . Results : There were no significant differences between EIS and EVL in the eradication rate of esophageal varices ( 85 % in the EIS group versus 81 % in the EVL group ) . The mean number of sessions required to obtain eradication was lower in the EVL group than in the EIS group ( 4.8 ± 1.8 versus 6.2 ± 2.0 ; p= 0.0003 ) , but the recurrence of esophageal varices was higher in the EVL group ( 31 % versus 11 % ; p= 0.01 ) . Total mortality was significantly lower in the EIS patients than in the controls ( 20 % versus 38 % ; p= 0.04 ) . It was also lower , but not significantly , in the EVL patients than in the controls ( 23 % versus 38 % ; p= 0.10 ) . A significant decrease in variceal bleeding was observed both in sclerotherapy cases ( 20 % ) and controls ( 54 % ; p= 0.0005 ) and in ligation cases and controls ( 29 % ; p= 0.01 ) . No significant difference in bleeding episodes was observed between the sclerotherapy and ligation cases ( p= 0.29 ) . No serious complications were observed either in the EIS or EVL groups . Conclusions : EIS and EVL are similarly effective in the prevention of first variceal bleeding . The choice between EIS and EVL depends on the skill of the endoscopic unit . For highly experienced surgeons facing no complications , sclerotherapy seems to be preferable ; for all others , it is technically easier to perform ligation Objective Non-selective β-blockers or endoscopic b and ligation ( EBL ) are recommended for primary prophylaxis of variceal bleeding in patients with oesophageal varices . Additional α-adrenergic blockade ( as by carvedilol ) may increase the number of patients with haemodynamic response ( reduction in hepatic venous pressure gradient ( HVPG ) of ≥20 % or to values < 12 mm Hg ) . Design Patients with oesophageal varices undergoing measurement of HVPG before and under propranolol treatment ( 80–160 mg/day ) were included . HVPG responders were kept on propranolol ( PROP group ) , while non-responders were placed on carvedilol ( 6.25–50 mg/day ) . Carvedilol responders continued treatment ( CARV group ) , while non-responders to carvedilol underwent EBL . The primary aim was to assess haemodynamic response rates  to carvedilol in propranolol non-responders . Results 36 % ( 37/104 ) of patients showed a HVPG response  to propranolol . Among the propranolol non-responders 56 % ( 38/67 ) eventually achieved a haemodynamic response  with carvedilol , while 44 % ( 29/67 ) patients were finally treated with EBL . The decrease in HVPG was significantly greater with carvedilol ( median 12.5 mg/day ) than with propranolol ( median 100 mg/day ) : −19±10 % versus −12±11 % ( p<0.001 ) . During a 2 year follow-up bleeding rates for PROP were 11 % versus CARV 5 % versus EBL 25 % ( p=0.0429 ) . Fewer episodes of hepatic decompensation  ( PROP 38%/CARV 26 % vs EBL 55 % ; p=0.0789 ) and significantly lower mortality ( PROP 14%/CARV 11 % vs EBL 31 % ; p=0.0455 ) were observed in haemodynamic responders compared to the EBL group . Conclusions Carvedilol leads to a significantly greater decrease in HVPG  than propranolol . Using carvedilol for primary prophylaxis a substantial proportion of non-responders to propranolol can achieve a haemodynamic response , which is associated with improved outcome with regard to prevention of variceal bleeding , hepatic decompensation and death BACKGROUND / AIMS Injection sclerotherapy has been used to prevent the first episode of variceal hemorrhage , but the results are controversial . The value of b and ing ligation in the prophylaxis of the first episode of variceal bleeding has not yet been completely evaluated . This study was conducted to determine whether prophylactic b and ing ligation is beneficial for cirrhotic patients with high-risk esophageal varices . METHODS A total of 127 cirrhotic patients with endoscopically-assessed high-risk esophageal varices but no history of bleeding were r and omized to undergo b and ing ligation  ( 64 patients ) or to serve as controls ( 63 patients ) . Ligation was performed at 3-week intervals until variceal obliteration was obtained . RESULTS During a median follow-up of 29 months , 14 patients ( 21.8 % ) in the ligation group and 22 patients ( 34.9 % ) in the control group experienced upper gastrointestinal bleeding ( p = 0.15 ) . Variceal bleeding occurred in eight patients ( 12.5 % ) in the ligation group and 14 patients ( 22.2 % ) in the control group ( p = 0.22 ) . Blood transfusion requirements were fewer in the EVL group than in the control group ( 0.6+/-0.4 units vs. 1.2+/-0.8 units , p<0.001 ) . Furthermore , variceal bleeding was significantly reduced in Child-Pugh class B patients treated with ligation compared with the control group ( p<0.05 ) . Sixteen patients ( 25 % ) in the ligation group and 23 patients ( 36.5 % ) in the control group died . Comparison of Kaplan-Meier estimates of time to death for the two groups did not show significant differences ( p = 0.19 ) . More patients died of uncontrollable variceal bleeding in the control group ( 7 patients , 11 % ) than in the ligation group ( 3 patients , 4.7 % ) ( p = 0.15 ) . CONCLUSIONS Although prophylactic ligation did not significantly reduce the first episode of bleeding from esophageal varices in cirrhotic patients with high-risk esophageal varices , a subgroup of patients ( Child-Pugh class B ) had a reduced frequency of the first episode of esophageal variceal bleeding after prophylactic b and ing ligation . Furthermore , there was a trend of reducing mortality from variceal bleeding in patients receiving prophylactic ligation . Prophylactic ligation is a promising treatment , but requires further investigation BACKGROUND Nonselective beta-adrenergic blockers decrease portal pressure and prevent variceal hemorrhage . Their effectiveness in preventing varices is unknown . METHODS We r and omly assigned 213 patients with cirrhosis and portal hypertension ( minimal hepatic venous pressure gradient [ HVPG ] of 6 mm Hg ) to receive  timolol , a nonselective beta-blocker  ( 108 patients ) , or  placebo ( 105 patients ) . The primary end point was the development of gastroesophageal varices or variceal hemorrhage . Endoscopy and HVPG measurements were repeated yearly . RESULTS During a median follow-up of 54.9 months , the rate of the primary end point did not differ significantly between the timolol group and the placebo group ( 39 percent and 40 percent , respectively ; P=0.89 ) , nor were there significant differences in the rates of ascites , encephalopathy , liver transplantation , or death . Serious adverse events were more common among patients in the timolol group than among those in the placebo group ( 18 percent vs. 6 percent , P=0.006 ) . Varices developed less frequently among patients with a baseline HVPG of less than 10 mm Hg and among those in whom the HVPG decreased by more than 10 percent at one year and more frequently among those in whom the HVPG increased by more than 10 percent at one year . CONCLUSIONS Nonselective beta-blockers are ineffective in preventing varices in unselected patients with cirrhosis and portal hypertension and are associated with an increased number of adverse events . ( Clinical Trials.gov number , NCT00006398 . Several treatments have been proven to be effective for variceal bleeding in patients with cirrhosis . The aim of this multicenter , prospect i ve , cohort study was to assess how these treatments are used in clinical practice and what are the posttherapeutic prognosis and prognostic indicators of upper digestive bleeding in patients with cirrhosis . A training set of 291 and a test set of 174 bleeding cirrhotic patients were included . Treatment was according to the preferences of each center and the follow-up period was 6 weeks . Predictive rules for 5-day failure ( uncontrolled bleeding , rebleeding , or death ) and 6-week mortality were developed by the logistic model in the training set and vali date d in the test set . Initial treatment controlled bleeding in 90 % of patients , including vasoactive drugs in 27 % , endoscopic therapy in 10 % , combined ( endoscopic and vasoactive ) in 45 % , balloon tamponade alone in 1 % , and none in 17 % . The 5-day failure rate was 13 % , 6-week rebleeding was 17 % , and mortality was 20 % . Corresponding findings for variceal versus nonvariceal bleeding were 15 % versus 7 % ( P = .034 ) , 19 % versus 10 % ( P = .019 ) , and 20 % versus 15 % ( P = .22 ) . Active bleeding on endoscopy , hematocrit levels , aminotransferase levels , Child-Pugh class , and portal vein thrombosis were significant predictors of 5-day failure ; alcohol-induced etiology , bilirubin , albumin , encephalopathy , and hepatocarcinoma were predictors of 6-week mortality . Prognostic re assessment including blood transfusions improved the predictive accuracy . All the developed prognostic models were superior to the Child-Pugh score . In conclusion , prognosis of digestive bleeding in cirrhosis has much improved over the past 2 decades . Initial treatment stops bleeding in 90 % of patients . Accurate predictive rules are provided for early recognition of high-risk patients OBJECTIVES To analyze sources search ed in Cochrane review s , to determine the proportion of trials included in review s that are indexed in major data bases , and to compare the quality of these trials with those from other sources . METHODS All new systematic review s in the Cochrane Library , Issue1 2001 , that were restricted to r and omized controlled trials ( RCTs ) or quasi- RCTs were selected . The sources search ed in the review s were recorded , and the trials included were checked to see whether they were indexed in four major data bases . Trials not indexed were checked to determine how they could be identified . The quality of trials found in major data bases was compared with those found from other sources . RESULTS The range in the number of data bases search ed per review ranged between one and twenty-seven . The proportion of the trials in the four data bases were Cochrane Controlled Trials Register = 78.5 % , MEDLINE = 
    Output:
    
This review found moderate-certainty evidence that , in patients with cirrhosis , b and ligation of oesophageal varices reduces mortality , upper gastrointestinal bleeding , variceal bleeding , and serious adverse events compared to no intervention .