Variceal bleeding is frequently the initial presentation of a previously unknown cirrhosis. Portal hypertension and its complications without liver cirrhosis should raise the possibility of presinusoidal portal hypertension, and the diagnosis of hepatoportal sclerosis. These patients need to be investigated for coagulation disorders. A hypercoagulable state is often associated. Risks and benefits of anticoagulation should be further investigated in these patients.
Superficial digestive tumours resection by endoscopic mucosal resection and sub-mucosal dissection causes very few complications according to the results obtained in expert centers. This work reports the rate of complications observed in a regional hospital, also comparing the results of their therapeutic management. The first 100 patients treated by endoscopic mucosal resection and sub-mucosal dissection, conducted by conventional techniques, were studied. The usual complications (stenosis, bleeding, perforation) were identified and details of their treatment reported. The overall complication rate was 16 %. Symptomatic stenoses are observed in 4 % of patients. Secondary bleeding occurs in 5 % of cases. Endoscopic management of these complications is effective in all cases, when it is attempted. Perforations complicate 7 % of the procedures. Two patients were assigned to surgery, successfully, the other 5 patients were treated by endoscopic sutures without damage. The complication rates observed in our department are comparable with results reported by the reference western centers. Their endoscopic management is usually successful and rescue surgery is unfrequent.La résection par mucosectomie et dissection sous-muqueuse des tumeurs digestives superficielles n’entraîne que très peu de complications selon les résultats obtenus dans les centres experts. Ce travail rapporte le taux de complications observé dans un centre hospitalier régional, comparant également les résultats de leur prise en charge. Les 100 premiers patients ayant été traités par mucosectomie et dissection sous-muqueuse, effectuées selon les techniques classiques, ont été étudiés. Les complications habituelles (sténoses, hémorragies et perforations) ont été répertoriées ainsi que les détails de leur traitement. Le taux global de complications est de 16 %. Les sténoses symptomatiques affectent 4 % des patients. Les hémorragies secondaires surviennent dans 5 % des cas. La prise en charge endoscopique de ces complications est efficace dans tous les cas, lorsqu’elle est tentée. Les perforations compliquent 7 % des procédures. Deux patients ont été confiés à la chirurgie, avec succès, les 5 autres patients ont été traités par sutures endoscopiques sans séquelle. Le taux de complications observé dans notre service est comparable aux résultats rapportés par les centres occidentaux de référence. Leur prise en charge endoscopique est régulièrement efficace et le recours à la chirurgie est peu fréquent.
The incidence of Barrett's esophagus, complication of gastroesophageal reflux disease, is rising in western countries. It is the same for esophageal adenocarcinoma, of which it is the main contributing factor. This retrospective study seeks to report the incidence of these pathologies observed in a regional hospital center and to describe their management. In 5 years, 354 Barrett's esophagus are detected and 34 of them are complicated by high-grade dysplasia or adenocarcinoma. Endoscopic resection is performed in 24 of these patients. The histological analysis of which leads to the conclusion of adenocarcinoma in 20 patients and high-grade dysplasia in the 14 others. The complications of endoscopic and surgical resections are detailed. Their frequency and severity remain low, comparable to data in the literature.L’incidence de l’œsophage de Barrett, complication du reflux gastro-œsophagien, est en croissance dans les pays occidentaux. Il en est de même de l’adénocarcinome œsophagien dont il est le principal facteur favorisant. Cette étude rétrospective s’attache à rapporter l’incidence de ces pathologies, observées dans un centre hospitalier régional, et à détailler leur prise en charge. En 5 ans, 354 œsophages de Barrett sont détectés et 34 d’entre eux sont compliqués de dysplasie de haut grade ou d’adénocarcinome. Une résection endoscopique est réalisée chez 24 de ces malades. Les analyses histologiques permettent de conclure à un adénocarcinome chez 20 malades et une dysplasie de haut grade chez les 14 restants. Les complications des résections endoscopiques et chirurgicales sont détaillées. Leur fréquence et leur gravité restent faibles, comparables aux données de la littérature.
BackgroundMucosal administration of monoclonal antibodies (mAbs) against respiratory pathogens is a promising alternative for systemic administration because lower doses are required for protection. Clinical development of mucosal mAbs is a highly active field yet clinical proof-of-concept is lacking.MethodsIn this investigator-initiated, double-blind, randomized placebo-controlled trial, we evaluated intranasal palivizumab for the prevention of RSV infection in preterm infants (Dutch Trial Register NTR7378 and NTR7403). We randomized infants 1:1 to receive intranasal palivizumab (1 mg/mL) or placebo once daily during the RSV season. Any RSV infection was the primary outcome and RSV hospitalization was the key secondary outcome. The primary outcome was analyzed with a mixed effect logistic regression on the modified intention-to-treat population.FindingsWe recruited 268 infants between Jan 14, 2019 and Jan 28, 2021, after which the trial was stopped for futility following the planned interim analysis. Adverse events were similar in both groups (22/134 (16.4%) palivizumab arm versus 26/134 (19.4%) placebo arm). There were 6 dropouts and 168 infants were excluded from the efficacy analyses due to absent RSV circulation during the SARS-CoV-2 pandemic. Any RSV infection was similar in infants in both groups (18/47 (38.3%) palivizumab arm versus 11/47 (23.4%) placebo arm; aOR 2.2, 95% CI 0.7–6.5).InterpretationDaily intranasal palivizumab did not prevent RSV infection in late preterm infants. Our findings have important implications for the clinical development of mucosal mAbs, namely the necessity of timely interim analyses and further research to understand mucosal antibody half-life.FundingFunded by the Department of Pediatrics, University Medical Centre Utrecht, the Netherlands.
SUMMARY Crohn’s disease (CD) is a multifactorial disease with genetic heterogeneity. TNF-α plays a key role in the development of the mucosal lesions. The aim of our work was to study a single base pair polymorphism located in the promoter region of TNF gene, in a large population of CD patients with well defined phenotypes. One hundred and ninety-three patients with CD and 98 ethnically matched controls were studied. The −308 single base pair polymorphism of TNF gene was studied using an allele-specific polymerase chain reaction. Genotype and allelic frequencies were compared between patients and controls and between subgroups of patients defined by sex, age at diagnosis, familial history, location of disease, type of disease, extra-intestinal manifestations, and response to steroid treatment. In 29 patients a measure of TNF-α production by colonic biopsies was performed. The frequency of the allele TNF2 as well as the proportion of carriers of the allele TNF2 were slightly but not significantly lower in CD than in controls (11.9% versus 14.8% and 21.5% versus 27.6%, respectively). A more prominent difference in frequencies of allele TNF2 and in proportions of TNF2 carriers was found when comparing subgroups of patients. The frequency of allele TNF2 was significantly higher in steroid-dependent than in non-steroid-dependent disease (28.1% versus 10.3%; Δ = 17.8%, 95% confidence interval (CI) = 6.3–29.5%, P = 0.0027) and tended to be higher in colonic than in small bowel disease and in fistulizing than in stricturing disease. Furthermore, TNF2 carriers tended to be more frequent in patients with steroid-dependent than non-steroid-dependent disease (43.8% versus 19.3%; Δ = 24.5%, 95% CI = 3.6–45.4%, P = 0.022), in patients with fistulizing than stricturing disease (26.5% versus 9.6%; Δ = 16.9%, 95% CI = 1.1–32.6%, P = 0.036), and in patients with colonic than small bowel disease (26.5% versus 11.1%; Δ = 15.4%, 95% CI = −0.8–31.6%, P = 0.063). Finally, patients carrying at least one copy of allele 2 were found to produce slightly more TNF-α at the colonic level. The −308 TNF gene polymorphism may have a slight influence on the behaviour of CD. The carriage of allele 2 may favour steroid-dependent disease and to a lesser extent fistulizing and colonic disease, possibly secondary to a more intense TNF-α-driven inflammatory reaction at the mucosal level.
Une hemorragie digestive secondaire a une rupture de varices oesophagiennes est regulierement revelatrice d'une cirrhose meconnue. L'observation d'une hypertension portale et de ses consequences sans alteration hepatique primitive doit faire penser a une hypertension portale pre-sinusoidale, et evoquer une sclerose hepatoportale. Chez ces patients, la recherche d'un trouble de coagulation est essentielle. Un etat prothrombotique est frequemment mis en evidence. Des etudes devront etre realisees de maniere a comparer les risques et les benefices d'un traitement anticoagulant chez ces patients.
Uncommon but classically described, intestinal carcinoid tumors represent a variety of neuroendocrine tumors. Able to secrete amines and hormones, they can produce characteristic symptoms called "carcinoïd syndrome". A cardiopathy is sometimes associated with the disease and carries a high risk of mortality and morbidity.
