Achalasia, also known as Esophageal achalasia, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by ...incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus (inability of smooth muscle to move food down the esophagus) in the absence of other explanations like cancer or fibrosis. In our experience, the echo-guided injection technique is the first procedure to implement to cure patients. After endoscopic-echo-guided injection technique, in patients presenting with refractory symptoms, the authors believe in surgical technique (extramucosal myotomy) as a good alternative technique to be implemented.
From 1999 to 2010, the authors have treated 36 patients (Group A), 24 male and 12 female (age 26-78) with diagnosis of esophageal achalasia. Patients underwent botulinum toxin injection during echo-guided identification of the lower esophageal sphincter. Results were compared with 32 patients (Group B) (age 36-78) who underwent blind treatment.
Patients of Group A presented complete relief of obstruction, patients of Group B had an obstruction remission in the 86% of the cases. Results were confirmed by manometric assessments in the early months after endoscopic treatment.
The authors emphasize the importance of the injection of botulinum toxin into the thicker area of the muscle layer of the lower esophageal sphincter. Patients undergoing echo-guided injection technique presented complete relief of obstruction, confirmed by manometric assessments in the early months after treatment.
A total gastrectomy with omentectomy and resection of the distal oesophagus in a 69‐year‐old haemophilia A patient with high inhibitor of 128 Bethesda units is described. Surgery was successfully ...performed after infusion of 112 μg kg–1 bw of recombinant FVIIa. Ninety‐two μg kg–1 were given thereafter at time intervals of 2 h until 12 h, then every 3 h until 24 h, and every 4 h until 48 h after surgery. Doses were gradually reduced in the following days and finally discontinued on day 28 after surgery. The complete treatment schedule required the administration of a total of 708 mg of recombinant FVIIa. Using this approach, we observed normal haemostasis, and there were no signs of excessive postoperative bleeding or wound haematoma. No clinical side‐effects or evidence of systemic activation of coagulation occurred during the treatment. As judged from the clinical course of this major surgery, recombinant FVIIa appears to be highly efficacious and safe and should be used as first line treatment in high titre inhibitor patients with cross‐reactivity to porcine factor VIII, undergoing surgery.
For managing highway bridges, stakeholders require efficient and practical decision making techniques. In a context of limited bridge management budget, it is crucial to determine the most effective ...breakdown of financial resources over the different structures of a bridge network. Bridge management systems (BMSs) have been developed for such a purpose. However, they generally rely on an individual approach. The influence of the position of bridges in the transportation network, the consequences of inadequate service for the network users, due to maintenance actions or bridge failure, are not taken into consideration. Therefore, maintenance strategies obtained with current BMSs do not necessarily lead to an optimal level of service (LOS) of the bridge network for the users of the transportation network. Besides, the assessment of the structural performance of highway bridges usually requires the access to the geometrical and mechanical properties of its components. Such information might not be available for all structures in a bridge network for which managers try to schedule and prioritize maintenance strategies. On the contrary, visual inspections are performed regularly and information is generally available for all structures of the bridge network. The objective of this paper is threefold (1) propose an advanced network-level bridge management system considering the position of each bridge in the transportation network, (2) use information obtained at visual inspections to assess the performance of bridges, and (iii) compare optimal maintenance strategies, obtained with a genetic algorithm, when considering interests of users and bridge owner either separately as conflicting criteria, or simultaneously as a common interest for the whole community. In each case, safety and serviceability aspects are taken into account in the model when determining optimal strategies. The theoretical and numerical developments are applied on a French bridge network.
Background. Patients with acute and chronic hepatitis B virus infection have elevated serum levels of soluble interleukin-2 receptor. This study examined patients with chronic hepatitis C virus ...infection to determine whether serum soluble interleukin-2 receptor levels were elevated and whether the degree of these elevations in serum levels correlated with histologic severity of hepatitis-related liver injury.
Methods. Percutaneous liver biopsies were performed on 123 patients with chronic hepatitis C virus infection. Serum levels of soluble interleukin-2 receptor in these 123 patients were measured by means of specific enzyme-linked immunoassay and were compared with levels in 174 subjects in a hepatitis-free control group.
Results. Soluble interleukin-2 receptor levels were significantly higher in the patients with hepatitis C than in subjects in a control group (p<0.0001). A progressive and significant increase occurred in soluble interleukin-2 receptor levels with increasing severity of liver injury (p<0.001). The highest levels of soluble interleukin-2 receptor occurred in patients who had hepatocellular cancer.
Conclusions. Soluble interleukin-2 receptor levels correlate with the histologic severity of liver damage in patients with chronic hepatitis C virus infection and may be useful as a marker in patients at high risk of getting hepatocellular cancer.
The epidermal growth factor receptor (EGFR) is overexpressed in 50-70% of human primary breast, lung, and colon carcinomas, whereas it is not usually expressed in hematopoietic cells. We developed a ...novel reverse transcription-PCR (RT-PCR)-Southern blot assay for the detection of circulating, EGFR mRNA-expressing tumor cells in carcinoma patients. The assay was set up by increasing the amount of cDNA step by step in the PCR reaction. The highest sensitivity and specificity were found when using 800 ng of cDNA in the PCR reaction. Peripheral blood samples from 91 patients with either colon (38), lung (30), or breast (23) carcinomas and from 38 healthy volunteers were analyzed. EGFR transcripts were found in 44 of 75 (59%) patients with metastatic carcinoma and in 4 of 38 (10.5%) healthy donors (P < 0.001; chi2 test). The expression of EGFR, cytokeratin 19, and carcinoembryonic antigen mRNA in blood samples from patients with metastatic colon carcinoma was compared. EGFR, cytokeratin 19, and carcinoembryonic antigen transcripts were found in 8 of 11 (73%), 3 of 11 (27%), and 5 of 11 (45%) patients, respectively. Furthermore, two of seven (29%) Dukes' B and five of nine (55%) Dukes' C colon carcinoma patients were found to express EGFR mRNA in the peripheral blood. All patients that expressed EGFR transcripts in the peripheral blood were found to express the EGFR protein in the corresponding primary carcinoma, as assessed by immunohistochemistry. These data suggest that the EGFR assay that we developed is a highly specific and sensitive technique to detect circulating tumor cells in patients affected by different carcinoma types.
Results from small randomised trials on tamoxifen in the treatment of hepatocellular carcinoma (HCC) are conflicting. We studied whether the addition of tamoxifen to best supportive care prolongs ...survival of patients with HCC.
Patients with any stage of HCC were eligible, irrespective of locoregional treatment. Randomisation was centralised, with a minimisation procedure accounting for centre, evidence of disease, and time from diagnosis. Patients were randomly allocated best supportive care alone or in addition to tamoxifen. Tamoxifen was given orally, 40 mg per day, from randomisation until death.
496 patients from 30 institutions were randomly allocated treatment from January, 1995, to January, 1997. Information was available for 477 patients. By Sept 15, 1997, 119 (50%) of 240 and 130 (55%) of 237 patients had died in the control and tamoxifen arms, respectively. Median survival was 16 months and 15 months (p=0·54), respectively. No differences were found within subgroups defined by prognostic variables. Relative hazard of death for patients receiving tamoxifen was 1.07 (95% CI 0.83–1.39).
Our findings show that tamoxifen is not effective in prolonging survival of patients with HCC.
