Surgical and endoscopic management of high grade dysplasia and early oesophageal adenocarcinoma.

BACKGROUND: The introduction of endoscopic techniques has led to debate about optimal management of early oesophageal adenocarcinoma. The aim was to evaluate patient selection and outcomes for endoscopic or surgical treatment at a tertiary referral centre. METHODS: A prospectively collected database of consecutive patients staged with high-grade dysplasia (HGD) or T1 oesophageal adenocarcinoma treated with curative intent between 2005 and 2013 was undertaken. All patients were discussed at the multidisciplinary team meeting. Surgical treatment was by thoracoscopic assisted or standard/laparoscopic assisted Ivor Lewis oesophagectomy. Endoscopic treatment was a structured programme of endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA). Outcomes included treatment variables, recurrence and complications. RESULTS: 83 patients treated; 50 with endoscopic therapy (EMR only-4, EMR then RFA-22, RFA only-24) and 38 by surgery (33 straight to surgery and 5 following EMR). Median age (67) and mean follow-up (21 months) were similar. HGD was more common in the endoscopic group (32/50, 64%, vs.3/33, 9%, p = 0.0001). Significant complications were more common following surgery (13/38, 34%, vs. 1/50, 2%, p = 0.0001). There were two in-hospital deaths following oesophagectomy (1 open, 1 thoracoscopic). Endoscopic treatment beyond 12 months for persisting HGD/intramucosal disease was required in 2 patients. Recurrence of HGD/invasive cancer was diagnosed in 2/36 (5.6%, T1a recurrence) of endoscopic and 1/38 (2.6%, T2N0 - subsequent hepatic metastases) surgical patients. CONCLUSION: A management algorithm including both endoscopic treatment and oesophagectomy provides optimal outcome for these patients. Due to additional morbidity of surgery, endoscopic treatment is appropriate first-line treatment.

[Long-term treatment of Alzheimer's disease: followup of a cohort of 255 patients treated with lacrine for four years]. / Traitement de la maladie d'Alzheimer au long cours: à propos d'une cohorte de 255 patients traités quatre ans par tacrine.

We describe the follow-up of a cohort of 255 Alzheimer's disease (AD) patients (81 males, 174 females) treated by tacrine during 4 years. We performed the survey of hepatic, cholinergic and general tolérance. Drug efficacy was measured by MMS examination on weeks 0, 18, 30, 52, 104, 156 and 208. A total of 190 patients (74.5 percent) were dropped out of this study, 75 (29 percent) for adverse events. We found 85 hepatic (33 percent), 79 cholinergic (31 percent), 31 (12 percent) neuropsychiatric and 72 general (28 percent) side effects. In term of drug efficacy we observed a global decline of 2.5 MMS points during the first year and 2 MMS points between W52 and W156. Tacrine's symptomatic efficacy, defined as the number of patients improved or stabilized at W30, was present in 50 patients (46 percent) among the 109 patients reaching W30. The intensity of symptomatic efficacy was expressed by a 2.7 MMS points increase in 37 patients improved on W30. The long term effects of Tacrine, measured by the MMS score at one year, showed a positive impact as the MMS was 2.5 points above the expected score in non treated AD patients. This study raises the practical problem of optimal cholinesterase inhibitors use in AD and the theoretical question of long term action of cholinesterase inhibitors on cerebral lesions of AD.

[Exercise test in patients over 70 years of age]. / L'épreuve d'effort sur bicyclette ergométrique chez le sujet de 70 ans et plus.

One hundred and sixty-four out of 171 prescribed tests were carried out (96 p. 100) in 48 women aged 70 to 85 years (mean 74,3 years), and 116 men aged 70 to 84 years (mean 73,4 years). The indications were: coronary artery disease (113 cases), cardiac arrhythmias (44 cases), cardiac failure (12 cases), hypertension (9 cases) and assessment of apparently normal subjects (7 cases). The tests were performed on a bicycle ergometer in the upright position; the work load was increased stepwise every 3 minutes with automatic electrocardiographic recording. 37.2 p. 100 of subjects exceeded 90 p. 100 of the maximal predicted heart rate for age; 23.2 p. 100 failed to achieve 75 p. 100 of the target heart rate. There were no serious complications but 4.2 p. 100 minor incidents occurred. The mean maximum work load was 66,5 watts (71.9 W for men and 53.5 W for women). These results show that exercise testing is possible in geriatric patients and provides information of comparable value to that obtained in younger patients. The investigation is safe when performed under strict medical supervision.

[Hypochromic anemia and small bowel diverticula]. / Anémie hypochrome et diverticules du grêle.

The authors appreciate the possible responsibility of small intestine diverticulosis in three patients with iron deficiency anemia. In the first case, anemia was associated with colo-duodenal fistula. In the second and third cases, because of the negativity of gastric and large bowel investigations, a barium opacification was done, which showed diverticulosis. This was considered as probably responsible for the anemia. After a review of the literature, the authors conclude that small intestine diverticulosis may lead to iron deficiency anemia through chronic blood loss.

[The effect of various diseases on the zinc plasma level]. / Influence de diverses pathologies sur le taux plasmatique du zinc.

Zinc, an important enzymatic cofactor, takes part in numerous metabolic pathways. In man, zinc deficiencies may be due either to deficient absorption or to excessive use. In this study in 285 patients hospitalized in a department of internal medicine for acute or chronic conditions, serum zinc assays have shown the following results: serum zinc concentrations are significantly decreased in acute critical conditions (cardiovascular ischemic disorders, heart failure, infections); in chronic conditions, serum zinc is decreased in some instances (renal failure, cancer, alcoholism, diarrhea), while it remains normal in others (compensated heart failure, non-insulin dependent diabetes, arterial hypertension, obesity). The fall in serum zinc concentrations is usually correlated with the severity of the clinical condition.

[Perforations of the colon and rectum during administration of barium enema. Six cases report (author's transl)]. / Les perforations recto-coliques au cours du lavement baryté. A propos de six observations.

Perforations of the colon and rectum during administration of barium enema. Six cases report. The authors have stated six cases of accidental perforation occurring during barium enema examination. They recall their principal modality of unexpected arrival, in particular: the type of nozzle used, the means of injecting the contrasting liquid, the role played by the pathological associated colon-rectum lesions. The diagnosis may be postponed especially when the perforation is under the peritoneal seat. The pain during or after the opacification as well as the rectorragies are the most frequent alarming symptoms observed. The prognosis is on the whole serious but is can be improved by a rapid and appropriate therapy.

[Angio-immunoblastic lymphadenopathy occurring two years after a hypersensitive vasculitis (author's transl)]. / Lymphadénopathie angio-immunoblastique survenant deux ans après une vascularite d'hypersensibilité.

The association of a drug related hypersensitive vasculitis followed two years later by angio-immunoblastic lymphadenopathy is reported. The hypothesis of a similar pathogenesis of these two conditions is discussed.

[Clinical value of the determination of serum digoxin levels (author's transl)]. / Intérêt clinique du dosage sanguin de la digoxine.

The authors refer to the technique of the serum digoxin enzyme immunoassay, and they report the results of 297 dosages concerning 111 hospitalized patients. The normal plasmatic rates are of 1,4 +/- 0,6 microgram/l in patients who present no sign of digitalic overdosage. The rates are of 5,2 +/- 1,6 microgram/l in cases of intoxication. The difference between these rates is greatly significant (p less than 0.001). The limit between therapeutic and toxic rates is situated around 3 microgram/l with an overlapping from 2 to 3 microgram/l. Authors then examine the individual factors that intervene in digoxin metabolism and especially study the influence of age, myocardic factors and renal insufficiency. On the basis of these results and review of the literature, they emphasize the interest of serum digoxin determination in the diagnosis of digitalis toxicity, as well as in the management of high risk patients, and of cardiopathies difficult to stabilize.

[Piribedil, dopaminergic agonist and the cerebral neurovascular syndrom of the aging man (author's transl)]. / Piribédil, agoniste dopaminergique et syndrome cérébral neuro-vasculaire du sujet âgé. Résultats d'un essai thérapeutique.

In the aging brain, there is an alteration of neurotransmettor systems, essentially catecholaminergics (dopamine, noradrenaline). The experimental works which show the agonist effect of piribedil on cerebral dopaminergic systems are presented. The results of the action of piribedil in the cerebral neuro-vascular syndrom are analysed.

[A case of idiopathic disseminated pulmonary ossification (author's transl)]. / Les ossifications pulmonaires disséminées idiopathiques. A propos d'une observation.

A patient aged 92 years was discovered to have disseminated pulmonary ossification of the interstitial tissues without any valvular cardiopathy. The authors underline the rarety of such ectopic ossifications and review their radiological, anatomical, and etiological characteristics as reported in the published literature.

[Pulmonary mycobacteriosis due to Mycobacterium chelonei: a report on a new case (authors' transl)]. / Mycobactériose pulmonaire à Mycobactérium chelonei. Une nouvelle observation.

Mycobacterium chelonei is a saprophytic germ usually devoid of pathogenic activity. Over a period of about the last ten years, however, several cases have been reported, including twelve cases of bronchopulmonary affections, in which it has been the infecting organism. The radiographic appearance is in every respect similar to that observed in pulmonary tuberculosis. A positive diagnosis of infection due to this germ can be made by the absence of Kuch's bacillus the lack of therapeutic effect of antituberculous medication, a positive skin reaction to specific antigens, and positive Mycobacterium Chelonei cultures from biopsy specimens. A new case of this infection is reported.