Diagnosis and treatment of pseudoachalasia: how to catch the mimic

Published: 25 June 2020Pseudoachalasia, or secondary achalasia, is an uncommon esophageal dysmotility syndrome with symptoms and manometric findings indistinguishable from primary achalasia, but due to any mechanism other than idiopathic degeneration of the inhibitory neurons of the esophageal submucosal myenteric plexus. Whilst pseudoachalasia is rare, affecting some 1.4–5.4% of all achalasia patients, it is essential this diagnosis is always considered and excluded, as the treatment and outcomes for these patients will be very different from those with true achalasia. Pseudoachalasia can be difficult to differentiate from primary or “idiopathic achalasia”. Several particular clinical features have been described as more common in patients with pseudoachalasia than in achalasia, but because of the low prevalence of this condition, the positive predictive value remains low. The majority of patients with pseudoachalasia have an underlying malignancy, predominantly gastro-esophageal adenocarcinoma, which is usually advanced. Management revolves around treating the underlying cause where possible, as this may lead to reversal of the esophageal dysmotility. In patients presenting with symptoms and manometry findings consistent with achalasia, the diagnosis initially should be one of an achalasia-like syndrome. Idiopathic achalasia can then only be confirmed after other potential causes have been considered and excluded. We describe a case of pseudoachalasia encountered in our clinical practice, followed by a review of current practice regarding diagnosis and management of pseudoachalasia.Dylan R. Barnett, George L. Balalis, Jennifer C. Myers, Peter G. Devit

License prices for financially constrained firms

It is often alleged that high auction prices inhibit service deployment. We investigate this claim under the extreme case of financially constrained bidders. If demand is just slightly elastic, auctions maximize consumer surplus if consumer surplus is a convex function of quantity (a common assumption), or if consumer surplus is concave and the proportion of expenditure spent on deployment is greater than one over the elasticity of demand. The latter condition appears to be true for most of the large telecom auctions in the US and Europe. Thus, even if high auction prices inhibit service deployment, auctions appear to be optimal from the consumers’ point of view

Uniqueness Theorem for Generalized Maxwell Electric and Magnetic Black Holes in Higher Dimensions

Based on the conformal energy theorem we prove the uniqueness theorem for static higher dimensional electrically and magnetically charged black holes being the solution of Einstein (n-2)-gauge forms equations of motion. Black hole spacetime contains an asymptotically flat spacelike hypersurface with compact interior and non-degenerate components of the event horizon.Comment: 7 pages, RevTex, to be published in Phys.Rev.D1

Oestrogen metabolites in relation to isoprostanes as a measure of oxidative stress

Objective  Oestradiol (E2) and its metabolites 2-hydroxyoestrone (2-OHE1) and 16Α-hydroxyoestrone (16Α-OHE1) are thought to curtail the greater oxidative stress found in the development and progression of disease conditions including atherosclerosis. We related oestrogen levels to F 2a -isoprostane levels, a biomarker of oxidative stress. Design and participants  Data were obtained from 1647 women, aged 47–57 years, participating in the fifth annual follow-up of the Study of Women's Health Across the Nation (SWAN), a study of the menopausal transition. Measurements  Serum E2 and urinary 2-OHE1 and 16Α-OHE1 concentrations were determined by enzyme-linked immunosorbent assay (ELISA) and urinary F 2a -isoprostanes were measured by enzyme immunoassay (EIA). Results  F 2a -isoprostane concentrations were elevated in women who smoked, a behaviour associated with increased oxidative stress, but not in stages of the natural menopause. Mean F 2a -isoprostane concentrations among pre- and postmenopausal women who smoked were 1082 and 1064 pg/ml, respectively, values double those in pre- (343 pg/ml) and postmenopausal (379 pg/ml) nonsmoking women. 2-OHE1 and F 2a -isoprostane concentrations were positively and highly correlated (partial correlations Ρ Y|X  = 0·44 and Ρ Y|X  = 0·43 in pre- and postmenopausal women, respectively). Similarly, 16Α-OHE1 concentrations were positively and highly correlated with F 2a -isoprostane concentrations (Ρ Y|X  = 0·52 and Ρ Y|X  = 0·59 in pre- and postmenopausal women, respectively). E2 was significantly correlated with F 2a -isoprostanes only in postmenopausal women (Ρ Y|X  = 0·20). Associations were adjusted for age, body mass index (BMI), race/ethnicity, lipids, physical activity level and alcohol consumption. Conclusions  This study does not support the commonly held hypothesis that levels of endogenous E2 or its oestrone metabolites favourably modify oxidative stress by decreasing F2 a -isoprostane levels.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74943/1/j.1365-2265.2007.03108.x.pd

Corrections to flat-space particle dynamics arising from space granularity

The construction of effective Hamiltonians describing corrections to flat space particle dynamics arising from the granularity of space at very short distances is discussed in the framework of an heuristic approach to the semiclassical limit of loop quantum gravity. After some general motivation of the subject, a brief non-specialist introduction to the basic tools employed in the loop approach is presented. The heuristical semiclassical limit is subsequently defined and the application to the case of photons and spin 1/2 fermions is described. The resulting modified Maxwell and Dirac Hamiltonians, leading in particular to Planck scale corrections in the energy-momentum relations, are presented. Alternative interpretations of the results and their limitations, together with other approaches are briefly discussed along the text. Three topics related to the above methods are reviewed: (1) The determination of bounds to the Lorentz violating parameters in the fermionic sector, obtained from clock comparison experiments.(2) The calculation of radiative corrections in preferred frames associated to space granularity in the framework of a Yukawa model for the interactions and (3) The calculation of synchrotron radiation in the framework of the Myers-Pospelov effective theories describing Lorentz invariance violations, as well as a generalized approach to radiation in Planck scale modified electrodynamics. The above exploratory results show that quantum gravity phenomenology provides observational guidance in the construction of quantum gravity theories and opens up the possibility of probing Planck scale physics.Comment: 49 pages, 6 figures and 4 tables. Extended version of the talk given at the 339-th WE-Heraeus-Seminar: Special Relativity, will it survive the next 100 years?, Potsdam, february 200

Lorentz and CPT Violation in Neutrinos

A general formalism is presented for violations of Lorentz and CPT symmetry in the neutrino sector. The effective hamiltonian for neutrino propagation in the presence of Lorentz and CPT violation is derived, and its properties are studied. Possible definitive signals in existing and future neutrino-oscillation experiments are discussed. Among the predictions are direction-dependent effects, including neutrino-antineutrino mixing, sidereal and annual variations, and compass asymmetries. Other consequences of Lorentz and CPT violation involve unconventional energy dependences in oscillation lengths and mixing angles. A variety of simple models both with and without neutrino masses are developed to illustrate key physical effects. The attainable sensitivities to coefficients for Lorentz violation in the Standard-Model Extension are estimated for various types of experiments. Many experiments have potential sensitivity to Planck-suppressed effects, comparable to the best tests in other sectors. The lack of existing experimental constraints, the wide range of available coefficient space, and the variety of novel effects imply that some or perhaps even all of the existing data on neutrino oscillations might be due to Lorentz and CPT violation.Comment: 25 pages REVTe

Short-term quality of life after myomectomy for uterine fibroids from the compare-uf fibroid registry

Background Uterine fibroids may decrease quality of life in a significant proportion of affected women. Myomectomy offers a uterine-sparing treatment option for patients with uterine fibroids that can be performed abdominally, laparoscopically (with or without robotic assistance), and hysteroscopically. Quality of life information using validated measures for different myomectomy routes, especially hysteroscopic myomectomy, is limited. Objective To compare women’s perception of their short-term health-related quality of life measures and reported time to return to usual activities and return to work for different routes of myomectomy. Materials and Methods Comparing Options for Management: Patient-centered Results for Uterine Fibroids (COMPARE-UF) is a prospective nationwide fibroid registry that enrolled premenopausal women seeking treatment for uterine fibroids at 8 clinical sites. For this analysis, we included women undergoing hysteroscopic, abdominal, or laparoscopic myomectomy who completed the postprocedure questionnaire scheduled between 6 and 12 weeks after surgery. Health-related quality of life outcomes, such as pain, anxiety, and return to usual activitie, were assessed for each route. The hysteroscopic myomectomy group had large differences in demographics, fibroid number, and uterine size compared to the other groups; thus, a direct comparison of quality of life measures was performed only for abdominal and laparoscopic approaches after propensity weighting. Propensity weighting was done using 24 variables that included demographics, quality of life baseline measures, and fibroid and uterine measurements. Results A total of 1206 women from 8 COMPARE-UF sites underwent myomectomy (338 hysteroscopic, 519 laparoscopic, and 349 abdominal). All women had substantial improvement in short-term health-related quality of life and symptom severity scores, which was not different among groups. Average symptom severity scores decreased about 30 points in each group. Return to usual activities averaged 0 days (interquartile range, 0–14 days) for hysteroscopic myomectomy, 21 days (interquartile range, 14–28 days) for laparoscopic myomectomy, and 28 days (interquartile range, 14–35 days) for abdominal myomectomy. After propensity adjustment, quality of life outcomes in the laparoscopic and abdominal myomectomy groups were similar except for more anxiety in the laparoscopic myomectomy group and slightly more pain in the abdominal myomectomy group. After propensity weighting, return to usual activities favored laparoscopic compared to abdominal procedures; median time was the same at 21 days, but the highest quartile of women in the abdominal group needed an additional week of recovery (interquartile range,14.0–28.0 for laparoscopic versus 14.0–35.0 for abdominal, P < .01). Time to return to work was also longer in the abdominal arm (median, 22 days; interquartile range, 14–40 days, versus median, 42; interquartile range, 27–56). Conclusion Women who underwent myomectomy had substantial improvement in health-related quality of life, regardless of route of myomectomy. After propensity weighting, abdominal myomectomy was associated with a nearly 2-week longer time to return to work than laparoscopic myomectomy

Black women are more likely than white women to schedule a uterine-sparing treatment for leiomyomas

Background: To evaluate differences in the proportion of uterine fibroid (UF) treatments that are uterine-sparing between Black women and White women and identify factors that could explain disparities. Methods: Women at age 18-54 years who were enrolled from 10 clinical sites in the United States into the Comparing Options for Management: Patient-Centered Results for UFs (COMPARE-UF) treatment registry completed questionnaires before their UF procedure. UF symptoms and quality of life were assessed by questionnaires. Details on UF imaging and treatment (hysterectomy, myomectomy, or uterine artery embolization [UAE]) were collected from each patient's medical record. Random-effects logistic regression was used to assess the association between race and the odds of having a uterine-sparing procedure versus hysterectomy. Subgroup analyses compared each uterine-sparing procedure with hysterectomy. Results: In this cohort of 1141 White women and 1196 Black women, Black women tended to be younger (median 41.0 vs. 42.0 years) and report worse symptoms, pain, and function on every scale compared with White women. Black women were more likely to have had a prior UF treatment compared with White women (22.8% vs. 14.6%). White women had more hysterectomies (43.6% vs. 32.2%) and myomectomies (50.9% vs. 50.2%) versus Black women. Black women had more UAEs (15.1% vs. 4.7%) than White women. After adjusting for clinical site and other variables, Black women had greater odds than White women of having a myomectomy (odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.63-3.56) or a UAE versus hysterectomy (OR = 4.24, 95% CI = 2.41-7.46). Conclusion: In these participants, Black women were more likely to schedule a uterine-sparing UF treatment and a nonsurgical UF treatment than their White counterparts; this may not be true for all women. Longer comparative effectiveness studies are needed to inform women about the durability of UF treatments. Greater understanding of factors influencing treatment selection is needed as are studies that include women without access to tertiary care centers. Clinical Trial Registration: Clinicaltrials.gov, NCT02260752 (enrollment start: November 2015)

Sociocultural considerations in aging men's health: implications and recommendations for the clinician

http://dx.doi.org/10.1016/j.jomh.2009.07.00