A Controversy That Has Been Tough to Swallow: Is the Treatment of Achalasia Now Digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux

IMPACT OF THE RECENT REFORMS ON INDIAN ARBITRATION LAW

In order to give effect to the UNICITRAL Model Law on Arbitration and due to radical change in its economy as the result of the 1991 New Economic Policy (NEP) India enacted the 1996 Arbitration & Conciliation Act. This Act provides a pragmatic legal basis for resolution of commercial disputes outside the court procedures. It circumscribes the older laws and consolidates multiple legal norms dealing with arbitration. However, the experiences in application of this Act for the last 20 years suggest that it needs to be amended as it contains serious drawbacks primarily due to poor legal technique which necessitated excessive judicial interventions and judicial overreach having led to resentment among those willing to resort to alternative dispute resolution under this Act while keeping the seat of Arbitration in India. Several attempts were made by the successive governments aiming at amending the 1996 Act. Yet all those attempts failed. Finally the present Union Government under the leadership of the Prime Minister Mr. Narendra Modi was able to bring in sweeping changes in existing arbitration law. These changes were carried out with the commitment of the Government in doing business in India through the Ordinance route and proper legislative procedures which finally led to the amendments having come into force on January 1, 2016. This paper attempts to analyse the key changes brought through the 2015 Amendment Act and their impact on the application of arbitration law in India. Moreover, the authors overview the prospects of India to acquire the preferred position in International Commercial Arbitration in the future as envisioned by the present Modi Government

TRIPS FLEXIBILITIES AND INDIA’S PLANT VARIETY PROTECTION REGIME: THE WAY FORWARD

Article 27.3(b) of the TRIPS Agreement provides that members shall provide for protection of plant varieties either by patents or by an effective sui generis protection or both. While WTO member countries can choose from among intellectual property strategies to protect plant varieties, they may not choose to exclude plant varieties from IP rights protection without facing trade sanctions from the WTO dispute resolution body. The open-ended language of the article creates a flexible standard of protection sympathetic to developing nations’ socio-economic priorities, provided that the effectiveness requirement is satisfied. This flexibility presents a range of possibilities from systems like the plant patent regime of the United States or specific variety protection systems of the European Union to the possibility of customized plant protection regimes suited to the needs of developing nations.India, while complying with the requirements of the TRIPS Agreement for the protection of plant varieties, enacted the Protection of Plant Varieties and Farmers’ Rights Act. The fundamental ideology of the PPVFR Act is to address India’s concerns about protecting the rights of small and marginal farming communities, while at the same time promoting plant breeding by vesting adequate IP rights protection which will boost further research and innovation in this field.This paper argues that as it is necessary to recognize and protect the rights of farmers in respect of their contribution made at any time in conserving, improving and making available plant genetic resources for the development of new plant varieties, the PPVFR Act has maintained a balance between breeders’ rights and farmers’ rights. The PPVFR Act protects farmers’ rights to save, use, exchange and share all farm produce, including seeds that fall within the purview of the Act, and it provides protection of indigenous knowledge against unwary monetization

The impact of the donor risk index on tumor free survival in patients undergoing liver transplantation with hepatocellular carcinoma.

In this study, we look at the impact of donor quality on tumor free survival in patients undergoing liver transplant (LT) with hepatocellular carcinoma (HCC) using the donor risk index (DRI) and its components. METHODS: We looked at all patients who underwent LT from March, 2002 to June, 2015 listed with the UNOS HCC exception. We excluded living donor recipients (214), multi-organ transplants (259), extrahepatic spread at LT (130) cholangiocarcinoma (79) and those who did not survive three months (585) leaving 16,416 patients. Patients were evaluated for tumor free survival using donor variables including DRI with Kaplan-Meier (KM) curves with log rank tests. Multivariate modeling was done using competing risks regression analysis. Recurrence data was obtained using post-transplant malignancy forms or cause of death data. RESULTS: Of the 16,416 patients transplanted with HCC exception, 2134 or 13.0% experienced HCC recurrence. Patients were divided into tertiles (Groups 1-3) by DRI. Group 1 had 5275 patients with mean DRI of 1.04 + 0.09 (range of 0.77-1.19). Group 2 contained 5610 patients with mean DRI of 1.38 + 0.11 (range of 1.2-1.57) and Group 3 had a mean DRI of 1.88 + 0.26 (range of 1.58-3.62). Three year tumor free survival for the three groups respectively was 89.2%, 88.2% and 87.7% and the difference was significant (P=0.001). On multivariate analysis, DRI remained significant with a HR of 1.21 (CI 1.09-1.34: P=0.003) per 1.0 point of DRI. In a separate multivariate analysis of the DRI components, donor age over 60 years (HR=1.15: CI 1.03-1.27: P=0.022), donor height (HR=0.99 per cm: CI 0.99-0.99: P=0.042) and national and regional sharing (HR=1.14: CI 1.03-1.24: P=0.017) remained significant whereas donor race, CVA as cause of death, cold ishemia time and DCD or split livers were not. CONCLUSIONS: In patients undergoing LT with HCC, decreased donor quality, as determined by the DRI, is associated with decreased tumor free survival. While the difference is significant on KM assessment and multivariate modeling, the numerical difference is small and is less than 2% at three years after LT. Individual variables of the DRI associated with decreased tumor free survival include older donor age, shorter donor height, and national and regional sharing

The clinical presentation of malignant pseudoachalasia.

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