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- Diagnosis involves endoscopy, barium swallow, and high-resolution manometry showing failure of the LES to relax. Treatment aims to reduce LES pressure and includes medications, botulinum toxin injection, pneumatic dilation, Heller's myotomy, and occasionally surgery. Newer treatments like peroral end
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Surgical options for Obstructive sleep apnoea syndromeGirish S
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The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
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Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
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Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
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Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
2. INTRODUCTION
• The term achalasia originated from the Greek word ‘khalasis’,meaning ‘failure to relax’.
• It is uncommon, with a prevalence of 1.8–12.6 per 100 000 persons per year.
• Primary Esophageal motility disorder.
• Also called as cardiospasm -because of severe spasm of the circular muscles of the lower end
of the esophagus.
• The contracted segment doesn’t relax during swallowing as a result there is a dilation,
tortuosity and hypertrophy of the esophagus above.
3. PATHOLOGY AND AETIOLOGY
• Remains uncertain but is postulated to be due to loss of the inhibitory ganglion cells in the
myenteric (Auerbach’s) plexus, possibly related to a virus-induced autoimmune effect.
• Histology of muscle specimens generally shows a reduction in the number of ganglion
cells with a variable degree of chronic inflammation.
• During a normal swallow, the food bolus will trigger primary peristalsis in the esophagus
by sequential activation of excitatory lower motor neurons.
• At the same time, relaxation of the LOS allows esophageal emptying.
4. PATHOLOGY AND AETIOLOGY
• With time, the esophagus dilates and contractions disappear, so that the esophagus empties
mainly by the hydrostatic pressure of its contents.
• This is nearly always incomplete, leaving residual food and fluid.
• The esophagus becomes progressively more tortuous and dilated (megaesophagus);
• Persistent retention esophagitis due to fermentation of food residues may predispose to the
increased incidence of carcinoma of the esophagus.
5. CLINICAL FEATURES
• The disease is most commonly diagnosed between 30 and 60 years of age.
• It typically presents with dysphagia (to both solid and liquid)
• Regurgitation and heartburn (often mistaken for GORD),
• Chest pain/odynophagia is also common in the early stages.
• Patients often present late and, having had relatively mild symptoms, remain untreated for
many years.
6. CLINICAL FEATURES
• Patients may or may not have experienced weight loss.
• Frequently, patients will adjust their diet according to symptoms and can maintain their body weight after an initial
drop.
• An ‘Eckardt score’ was developed to assess the severity of symptoms and monitor treatment outcome
• Aspiration-related respiratory symptoms and pneumonia can also occur when there is significant stasis of food
residue in the dilated esophagus.
• The retained food substance can cause fermentation and therefore halitosis.
• Patients may report regurgitating food that they have ingested before.
9. DIAGNOSIS
• A high index of suspicion is needed in the diagnosis of achalasia as symptoms can be mild
and chronic and can be easily misdiagnosed as GORD.
• Endoscopy typically shows frothy saliva pooling in the esophagus and the presence of food
residue.
• The esophagus may be dilated and can be tortuous.
• The OGJ appears tight and spastic but can usually allow an endoscope to pass with gentle
pressure.
• A normal endoscopy however does not exclude achalasia, as 30–40% of endoscopies are
reported as normal before a final diagnosis of achalasia is made.
10. DIAGNOSIS
• Barium contrast study typically shows a hold-up of contrast in the distal esophagus.
• Abnormal contractions in the esophageal body and a tapering stricture in the distal
esophagus, described as a ‘bird’s beak’ or ‘rat’s tail.’
• All these investigations are suggestive of achalasia but definitive diagnosis relies on
HRM.
11.
12.
13.
14. • HRM- (GOLD STANDARD)
• It shows unrelaxed LES with high resting pressure
• It shows failure of the LES to relax completely during swallowing and complete absence
of peristalsis.
15.
16.
17. • It is an important investigation to exclude ‘pseudo-achalasia’, often
referring to cancer of the gastric cardia mimicking achalasia.
• Oesophagoscope is done to confirm the diagnosis and to rule out carcinoma esophagus.
• It shows totally closed LES with atonic, dilated proximal esophagus.
• Biopsy of the mucosa at LES should be done.
18.
19. TREATMENT
• The treatment goal of achalasia is for symptom palliation since there is no therapy to
reverse the neuronal degeneration.
• Therapies target the LOS, aiming to reduce its contractility by pharmacological means or
by destroying the muscle fibers using endoscopic or surgical methods.
20. MEDICAL THERAPY
• Calcium channel blockers, nitrates or 5′-phosphodiesterase inhibitors are used to
reduce the LOS pressure.
• Most have limited efficacy in symptom improvement.
• There are also significant side effects, such as headache, oedema and hypotension, after
repeated doses.
• Medical therapy should be reserved for selected patients who are poor candidates for
endoscopic or surgical treatments
21. BOTULINUM TOXIN
• Botulinum toxin is a potent presynaptic inhibitor of acetylcholine release from nerve endings.
• When injected endoscopically into the LOS, it interferes with the LOS cholinergic excitatory
neural activity and paralyses the sphincter muscle.
• The injection usually has to be repeated after few months. Because the effect is temporary, it is sometimes used
when the diagnosis of achalasia is in doubt.
• Repeated injection may result in scarring, making subsequent treatments more difficult.
• It should not be offered as first-line treatment in patients who are suitable for myotomy or pneumatic dilatation
and its indication is usually restricted to elderly patients with comorbidities.
22. PNEUMATIC DILATATION
• This involves stretching the LOS with a non-compliant balloon to disrupt the sphincter
muscle and render it less competent.
• Plastic (polyethene) balloons with a precisely controlled external diameter are used.
• Balloons of 30–40 mm in diameter are available and are inserted over a guidewire. There
is no standardized dilatation protocol.
• Generally, it is preferred to have serial dilatations in a graded manner, from 30 mm to 35
mm and 40 mm.
• Serial pneumatic dilatation has similar efficacy to surgical myotomy in selected patients.
23. PNEUMATIC DILATATION
• Perforation is uncommon; the reported incidence averaged about 1.9% (0–16%).
• With a 30-mm balloon, the chance of perforation should be less than 0.5%.
• The risk of perforation increases with bigger balloons, which should be used cautiously
for progressive dilatation over weeks.
• It is important to have an experienced endoscopist performing the procedure and surgical
back-up in case of perforation
24. HELLER'S MYOTOMY
• This involves cutting the muscle of the lower esophagus and gastric cardia.
• Typically, anterior myotomy is performed for at least 6 cm proximally at the esophageal side and 2–3 cm distally into
the gastric cardia.
• Transabdominal or transthoracic approaches have been advocated.
• Currently, the standard procedure is a laparoscopic approach.
• The major complication is GORD, which can occur in up to 40% of patients.
• The addition of a partial fundoplication (anterior Dor or posterior Toupet) has been shown to be effective in reducing
the incidence of GORD.
25. HELLER'S MYOTOMY
• A complete 360° fundoplication (Nissen) is considered contraindicated because the
increase in outflow resistance against a peristaltic esophageal body which will probably
result in postoperative dysphagia.
• Laparoscopic myotomy is superior to single pneumatic dilatation in efficacy
and durability.
26.
27. PERORAL ENDOSCOPIC MYOTOMY
• Peroral endoscopic myotomy (POEM) involves opening the mucosa at a short distance proximal to
the intended myotomy site.
• Entrance is gained into the submucosal plane, which is extended distally to about 2–3 cm into the
gastric cardia. The circular +/– longitudinal muscles are then cut using ESD instruments.
• Typically, the myotomy extends a minimum of 6 cm in the esophagus proximally and 2 cm into the
gastric cardia distally. The mucosal opening is then closed with endo clips.
28.
29. • POEM has the advantage in that it can extend the length of the myotomy proximally
• POEM can also be utilized to treat other types of ‘spastic’ esophageal motility disorders
such as distal esophageal spasm and hypercontractile esophagus.
• Randomized controlled trials have demonstrated similar efficacy of POEM to pneumatic
dilatation and Heller’s myotomy in relieving dysphagia.
• Without any antifix procedure, the incidence of GORD is expectedly higher in POEM
compared with Heller’s myotomy with partial fundoplication.
• The incidence of esophagitis at 3 months after POEM can be as high as 57%, which may
subject patients to lifelong acid suppression therapy or subsequent antireflux operation.
30. OESOPHAGECTOMY
• Oesophagectomy is reserved only for the treatment of patients with ‘end-stage’ achalasia
with a sigmoidal or megaesophagus who are not responding to other methods.
• A grossly dilated oesophagus predisposes to regurgitation and aspiration pneumonia.
• Balancing the risk of an oesophagectomy with the patient’s quality of life and risk of
aspiration complication, surgery can be a reasonable option for surgically fit patients.
31. FOLLOW UP
• Treatment success is usually define by symptom relief.
• The Eckardt score is quantified and compared with the preoperative score.
• Patients should be counselled on a post-treatment diet as the oesophageal body motility
remains defective.
• Ideally,HRM, barium contrast study, endoscopy and 24-hour pH monitoring should be
performed postoperatively to objectively assess LOS function, bolus retention, response to
treatment, presence of oesophagitis and acid reflux.
• This depends on the availability of resources and patients’ preference.