Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

Cutaneous adverse events: a predictor of tumour response under anti-PD-1 therapy for metastatic melanoma, a cohort analysis of 189 patients

INTRODUCTION

Cutaneous adverse events (AEs) are the most prevalent toxicity under checkpoint inhibitors in clinical trials. In 'real-life' conditions of use, skin toxicities under anti-PD-1 have not been described to date in a large cohort. The objective of this study was to determine the clinical features of skin toxicities in patients with advanced melanoma receiving anti-PD-1 therapy under 'real-life' conditions of use. Secondary objectives were to evaluate the characteristics of patients with skin toxicities and to analyse associated extra-cutaneous toxicities, progression-free survival (PFS) and overall survival (OS).

PATIENTS AND METHODS

Advanced melanoma patients treated with nivolumab or pembrolizumab between August 2014 and October 2017 were included. Patients lost to follow-up or receiving anti-PD-1 as part of a clinical trial were excluded.

RESULTS

One hundred and eighty-nine patients with metastatic melanoma (with 109 men (57.7%) were included. Cutaneous AE occurred in 39 patients (20.6%). The three most prevalent cutaneous AEs were skin eruption (macular-papular or eczematous) (n = 18, 9.5%), vitiligo (n = 16; 8.5%) and isolated pruritus (n = 5, 2.6%). Grade 3-4 skin toxicity was diagnosed in five patients (2.6%). Atopy (28.2% vs. 12.0%; P = 0.024), hypereosinophilia (20.5% vs. 8.7%; P = 0.046), thyroiditis (17.9% vs. 4.7%; P = 0.011) and renal toxicity (15.4% vs. 4%; P = 0.019) were significantly associated with cutaneous AE. Patients with skin eruption (log-rank = 0.001), vitiligo (log-rank = 0.001) and any type of cutaneous AE (log-rank < 0.001) had a better overall survival.

CONCLUSIONS

Cutaneous AEs are frequent and often manageable toxicity and were a predictor of tumour response in melanoma patients under anti-PD-1 therapy in this cohort.

61 Targeting Elderly Patients on Inhaled Corticosteroids for Respiratory Optimisation

Introduction

Inhaled corticosteroids (ICS) are associated with increased rates of pneumonia, fracture and diabetes. ICS have limited short and long term benefits in COPD, and cessation of steroids in selected patients has been proven safe. We observed that a large proportion of inpatients in the geriatric service were prescribed ICS, and we aimed to review the reasoning for this and introduce a program of respiratory review in order to optimise care in these patients.

Methods

We conducted a retrospective audit of patients discharged from a geriatric service over a 3 month period. Sequential discharges were assessed for the presence and type of inhaled therapies, the documented diagnosis. After identifying high rates of inhaled therapy usage, we undertook a series of quality improvement interventions aimed at optimising respiratory care in these elderly patients. This included a guideline based protocol for reviewing respiratory diagnoses and prescriptions.

Results

In the retrospective analysis, 67/297 (22.5%) patients were discharged on inhaled therapy. 55/67 (82%) were discharged on an ICS, of which 20/67 (36%) were on high doses, equivalent to &gt;1000micrograms of beclomethasone. Very few of these patients had evidence of inhaled therapy review during admission. 15/55 of these patients were given a discharge diagnosis of pneumonia; whilst only 6/55 were admitted with an exacerbation of their COPD. Our preliminary data suggest that a single paged protocol aimed at improving adherence to best practice lead to practice change: Dose modification has occurred in 50% of patients on ICS, leading to a reduction in steroid burden, and an annual reduction in prescription costs of £75 per patient reviewed. None of these patients have been re-admitted with respiratory exacerbations.

Conclusions

By introducing measures to assist in the review and modification of inhaled therapies, we were able to change practice. The alteration in practice led to reduction in prescription costs, and a reduced burden of inhaled corticosteroids. We propose that widespread encouragement of geriatrician led respiratory review could lead to harm reduction and cost saving in elderly inpatients.

Use of non-invasive ventilation in children with congenital tracheal stenosis

INTRODUCTION

Congenital tracheal stenosis (CTS) is a rare airway condition characterized by complete tracheal rings. Most patients undergo a slide tracheoplasty, which greatly reduces mortality but significant morbidity remains. The assessment of sleep disordered breathing (SDB) and use of non-invasive ventilation (NIV) in these children has not been described.

AIM

To describe the presence of SDB and use of NIV in children diagnosed with CTS over a 10-year period (2005-2015).

DESIGN

Retrospective case series at a tertiary children's hospital.

RESULTS

There were 16 patients identified with CTS with a median [range] age at diagnosis of 2.5 months (0-9 months). One child died in the immediate post-operative period following a slide tracheoplasty, leaving 15 survivors. There were no later deaths during follow-up while using NIV for up to 3 years after surgery. Slide tracheoplasty was undertaken in (12/15) with long-segment tracheal stenosis. 3/15 patients had a short-segment tracheal stenosis and were managed conservatively. The use of NIV occurred in 10/15 (66.67%) patients, all of whom had long-segment CTS. Pre-operative polysomnography (PSG) showed a median (±SD) obstructive apnoea/hypopnoea index (OAHI) of 14.6/hr (±6.2) which reduced to 7.2/hour (±4.2) on NIV prior to slide tracheoplasty. The median oxygen desaturation index (ODI) before NIV use was 15.3 (±19.4) episodes/hour, which reduced to 6.3 (±11) on NIV. The median period of NIV use was 5 [1-24 months] months.

CONCLUSION

Patients with CTS have obstructed sleep disordered breathing. Trials of NIV are well-tolerated and improve sleep disordered breathing.

MRI hip findings in asymptomatic professional rugby players, ballet dancers, and age-matched controls

AIM

To investigate hip magnetic resonance imaging (MRI) findings in asymptomatic professional male rugby players and male ballet dancers compared to age-matched controls.

MATERIALS AND METHODS

After ethics committee approval and consent from participants, 11 professional rugby players, 10 professional ballet dancers, and 10 controls completed activity and symptom questionnaires and underwent 3 T MRI of their self-declared dominant hip. Each scan was independently scored by two musculoskeletal radiologists for multiple features, including: joint morphology, acetabular labrum appearance, cartilage loss, and capsular thickness. Clinical and MRI features were assessed for variance by group using one-way analysis of variance (ANOVA) tests and Tukey post-hoc pairwise comparison of means.

RESULTS

Labral tear prevalence was 87% with no significant difference between groups (p>0.05). Rates of paralabral cysts were significantly higher in ballet dancers (50%), compared to rugby players (0%) and controls (10%; p=0.01). Acetabular cartilage loss was present in 54% with no significant differences between groups. Superior capsular thickness was significantly greater in ballet dancers (5.3 mm) compared to rugby players (3.8 mm) and controls (3.8 mm; p=0.03).

CONCLUSION

Despite the difference in type of activity between groups, there were equally high rates of labral tears and acetabular cartilage loss, questioning the role that sport plays in the development of these findings and their relationship to symptoms. The focally increased superior capsular thickness in ballet dancers may be an adaptive response to extreme ranges of movement.

Enhanced recovery after anterior resection: earlier leak diagnosis and low mortality in a case series

INTRODUCTION

Early detection and treatment of anastomotic leak may mitigate its consequences. Within an enhanced recovery setting, the subtle signs of a leak can be more apparent. There are multiple treatment options for anastomotic leak following anterior resection. This study aimed to determine when leaks are diagnosed in enhanced recovery, and whether the choice of intervention affects outcomes.

MATERIALS AND METHODS

We conducted a retrospective study of a prospectively maintained database of complications of anterior resections for rectal cancer in a district general hospital in the UK. Data were extracted on day of leak diagnosis, length of stay, intensive care admission, mortality and ileostomy reversal rate. Statistical analysis was performed using Student's t, Mann-Whitney U and chi square tests.

RESULTS

A total of 323 patients underwent anterior resection for colorectal cancer between 1 January 2007 and 1 October 2015. The leak rate was 10.8% (35/323). Patients were diagnosed in hospital with leaks on median day 4 compared with day 11 for patients diagnosed with leaks after readmission from home (P < 0.001). Defunctioned patients diagnosed with a leak had a longer median length of stay (24 vs 18.0 days, P = 0.31) but were more frequently managed non-operatively (100% vs 19.0%, P < 0.001) and had a lower admission rate to intensive care (9.5% vs 42.9%, P = 0.02) than patients who were not defunctioned at time of resection. Overall mortality from anastomotic leak was 2.9% (1/35). Ileostomies were reversed in 73.5% of patients (25/34).

DISCUSSION

Enhanced recovery enables early diagnosis of leaks following anterior resection. Defunctioning of patients with anastomotic leak lowers mortality.

Abstract P4-16-10: Bone health in young women with breast cancer

Introduction:

There are limited data and consensus regarding bone mineral density (BMD) monitoring, and management of bone loss in younger women with breast cancer (BC). Adjuvant endocrine therapy for estrogen receptor positive (ER+) BC may include ovarian function suppression (OFS) plus use of aromatase inhibitors (AIs) for 5-10 years, both of which contribute to bone loss. The WHO risk prediction tool FRAX does not include BC or AI use as independent risk factors in its calculation thus underestimating risk of fracture. This study aims to evaluate current screening and management of bone health in young women with BC.

Methods:

A retrospective, IRB-approved chart review was performed in consecutive women ≤40 with BC diagnosed at Loyola University Chicago Medical Center between 01/01/2015 and 12/13/17. Demographic data, BC treatment, and factors contributing to secondary causes of bone loss were collected through 4/1/18. A descriptive analysis included summary values for all categorical and continuous risk factors.

Results:

BC ≤40yrs was identified in 136 women; 18 were excluded due to missing data. The analysis was performed on 118 patients (pts). Mean pt age was 34.6 yrs (SD 4.7). Stage at diagnosis included: stage 0 = 9 (7.6%), stage 1 = 26 (22%), stage 2 = 44 (37.3%), stage 3 = 23 (19.5%), stage 4 = 7 (5.9%), unknown = 9 (7.6%). Seventy-nine (67%) had ER+ BC; 32 (27.1%) had HER2-positive disease. The majority of pts (101, 85.6%) received chemotherapy in their treatment plan. Menopause was documented in 69 (59.0%) pts. Goserelin was used in 31 pts (44.9%), oophorectomy in 17 (24.6%), both in 5 (7.2%). Tamoxifen was used in 44 (55.7%) ER+ pts; 34 (43.0%) received an AI, and 18 (22.8%) received sequential tamoxifen and AI. 25 Hydroxy-Vitamin D (25 OHD) levels were checked in 61 (51.7%); 43 (70.5%) had levels &lt;30 ng/ml; 24 (55.8%) received vitamin (vit) D supplementation. There was no difference in the 25 OHD in pre- and post-menopausal women (p=0.64). Pts with vit D deficiency had a median BMI of 26.8 vs 23.8 in those with sufficient vit D levels (exact p=.049). Secondary diagnoses contributing to low BMD were identified in 14 (11.8%). Dual energy xray absorptiometry (DXA) scans were checked in 23 pts (19.7%), 18 of whom were post-menopausal. At the femur, 0 pts had a z-score (age-matched standard deviation) of ≤-2.0, 9 pts (39.1%) had a score between 0 to -2.0. At the lumbar spine, 1 pt (4.3%) had a z-score ≤-2.0, 9 pts (39.1%) had a z-score between 0 to -2.0. No T-scores were in the osteoporosis range; 11 pts had T-scores at both femur and lumbar spine in the osteopenia range. The median 10 yr probability of a major osteoporotic fracture (FRAX score) was 1.9% (1.6-2.7%); the median 10 yr probability for hip fracture was 0.1% (0.10-0.20%). There were no differences in FRAX scores between pre- and post-menopausal women. No fractures were reported in the time period studied. Anti-resorptive therapy was used only in patients with metastatic bone disease.

Conclusions:

25 OHD and DXA scans are not routinely checked in younger women diagnosed with BC. Vit D deficiency and evidence of bone loss is prevalent in those pts who do undergo testing. Further research and guidelines are necessary to address management of bone health in young women with BC to minimize future fracture risk and morbidity.

Citation Format: Wendell KB, Nadeem S, Martin B, Camacho PM, Albain KS, Robinson P, Lo SS. Bone health in young women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-10.

Promoting oral potassium administration in a tertiary care hospital: An eleven-year study

INTRODUCTION

Potassium is used to treat or prevent hypokalemia and exhibits all the characteristics of an intravenous to oral therapy conversion program. Despite this, the intravenous route for potassium replacement seems frequently unjustified.

OBJECTIVES

To determine the impact of a conversion program on the use of intravenous and oral galenic forms in a university tertiary care hospital.

METHODS

Two promotion campaigns were conducted in 2006 and 2009. The following years this was completed by pharmacist interventions during prescription analysis and face-to-face discussions with physicians during ward rounds. The consumption of products containing potassium was obtained by analyzing the hospital's financial database.

RESULTS

The proportion of the oral route increased from 18% in 2006 to 22% in 2011, and from 25% in 2012 to 44% in 2016; the increase was significantly greater in the second period (P<0.0001). In 2016, in emergency, pulmonology, infectious diseases, and cardiology departments, the proportion of oral use ranged from 57% and 82%. The greatest progression from 2006 to 2016 was found for intensive care (4% vs. 12%) and visceral surgery departments (9% vs. 34%) that increased approximately four-fold, followed by the emergency department (28% vs. 57%) that increased approximately two-fold.

CONCLUSION

Promoting the oral route for potassium replacement modifies prescriber habits and is followed by a notable increase in the proportion of potassium administered orally irrespective of department type.

Epilepsy surgery: A therapeutic patient education program

Before the creation of a therapeutic patient education (TPE) program for epilepsy surgery, a needs analysis was conducted with 29 people, including patients (n=13), family members (n=9) and healthcare providers (n=7). Most of them highlighted the psychological difficulties of the surgical process, and the need for considerably more precise information concerning the immediate postoperative period. In addition, several patients and/or family members requested meeting with a patient who had undergone the surgery. The majority of subjects were interested in epilepsy-surgery TPE. These data were important in the creation of our TPE program and, more generally, for the management of these patients.

Evaluation of large clinically atypical vulvar pigmentation with RCM: atypical melanosis or early melanoma?

BACKGROUND

Vulvar melanosis can occasionally be clinically challenging by mimicking an early melanoma.

OBJECTIVE

To report our experience of initial evaluation and follow-up in this peculiar subset of vulvar melanosis using reflectance confocal microscopy (RCM).

METHODS

We retrospectively evaluated 18 consecutive cases referred for atypical vulvar pigmentation or for which melanoma was considered and that underwent both RCM examination and histopathological assessment. In 13 cases with available dermoscopic pictures, RCM classification was compared to dermoscopic diagnosis, and in all cases, the density of melanocytes was evaluated on biopsies using MelanA immunostaining.

RESULTS

Among the 18 atypical pigmented lesions, 17 vulvar melanosis and one melanoma were histologically determined. RCM concluded a benign vulvar melanosis in 10 of 17 cases, whereas dermoscopy did so in three of 12 cases. RCM identified the only early malignant lentiginous melanoma. In several cases of vulvar melanosis, RCM could identify foci of melanocytic hyperplasia in an otherwise benign pattern.

CONCLUSIONS

In this clinically and dermoscopically challenging subset of vulvar pigmentations, RCM appears relevant for initial extensive evaluation, especially to target initial biopsy sampling, and to perform non-invasive monitoring of foci of melanocytic hyperplasia.

The impact of sexual orientation on body image, self-esteem, urinary and sexual functions in the experience of prostate cancer

Prostate cancer (PCa) poses a large health burden globally. Research indicates that men experience a range of psychological challenges associated with PCa including changes to identity, self-esteem and body image. The ways in which sexual orientation plays a role in the experience of PCa, and the subsequent impact on quality of life (QoL), body image and self-esteem have only recently been addressed. By addressing treatment modality, where participant numbers were sufficient, we also sought to explore whether gay (homosexual) men diagnosed with PCa (PCaDx) and with a primary treatment modality of surgery would report differences in body image and self-esteem compared with straight (heterosexual) men with PCaDx with a primary treatment modality of surgery, compared with gay and straight men without PCaDx. The results of our study identified overall differences with respect to PCaDx (related to urinary function, sexual function and health evaluation), and sexual orientation (related to self-esteem), rather than interactions between sexual orientation and PCaDx. Gay men with PCaDx exhibited higher levels of urinary functioning than straight men with PCaDx, the difference being reversed for gay and straight men without PCaDx; but this result narrowly failed to achieve statistical significance, suggesting a need for further research, with larger samples.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Utility of single versus multiple breath washout in adult asthma

Nitrogen multiple breath washout (N2 MBW) is a sensitive method to identify peripheral airway involvement in asthma, but is a time-consuming test. The N2 vital capacity single breath (VC SBW) test offers greater time efficiency, but concordance with N2 MBW is poorly understood. The prevalence of peripheral airway abnormality was determined by N2 MBW and N2 SBW tests in 194 asthmatic subjects aged 18-1 years. N2 MBW data were related to findings in 400 healthy controls, aged 17-71 years, while N2 SBW data were compared to findings in 224 healthy controls, aged 15-65 years, to derive equipment-specific reference values. Amongst asthmatic subjects, relationships between N2 SBW and N2 MBW outcomes were studied. N2 SBW relationship with clinical history, spirometry, blood eosinophils and fraction exhaled nitric oxide (FENO) data was also explored. The prevalence of peripheral airway involvement (i.e. abnormal ventilation distribution) determined by N2 SBW-derived phase III slope (N2 SIII ) was 24·7%, compared to 44% determined by N2 MBW-derived lung clearance index (LCI) (P<0·001). Predictors of abnormal N2 SIII were older age, smoking history and lower FEV1. N2 SBW offers lower sensitivity than N2 MBW to detect small airway dysfunction in adult asthma, but may be a marker of more severe disease.

3D kinematics of the interphalangeal joints in the forelimb of walking and trotting horses

The objective was to measure 3D rotations of the distal (DIP) and proximal (PIP) interphalangeal joints at walk and trot. 3D trajectories of markers fixed to the proximal phalanx, middle phalanx and the hoof wall of the right forelimb of four sound horses were recorded at 120 Hz. Joint kinematics were calculated in terms of anatomically-based joint coordinate systems between the bone segments. Ranges of motion were similar at walk and trot. Values for the DIP joint were: flexion/extension: 46 ± 3° at walk, 47 ± 4° at trot; internal/ external rotation: 5 ± 1° at walk, 6 ± 3° at trot; and adduction/abduction: 5 ± 2° at walk, 5 ± 3° at trot. Within each gait, kinematic profiles at the DIP joint were similar between horses with the exception of adduction/abduction during breakover, which may vary depending on the direction of hoof rotation over the toe. Knowledge of the types and amounts of motion at the DIP joint will be useful in understanding the aetiology and treatment of injuries to the soft tissues, which are being recognized more frequently through the use of sensitive imaging techniques. Ranges of motion for the PIP joint were: flexion/extension: 13 ± 4° at walk, 14 ± 4° at trot; adduction/abduction: 3 ± 1° at walk, 3 ± 1° at trot; and internal/external rotation: 3 ± 1° at walk, 4 ± 1° at trot. The PIP joint made a significant contribution to flexion/extension of the digit. During surgical arthrodesis, the angle of fusion may be important since loss of PIP joint extension in late stance is likely to be accommodated by increased extension of the DIP joint.

Do ultrasound guided trochanteric bursa injections of corticosteroid for greater trochanteric pain syndrome provide sustained benefit and are imaging features associated with treatment response?

AIM

To assess intra-bursal corticosteroid injections (ICSI) efficacy and duration of action in the management of greater trochanteric pain syndrome (GTPS). The secondary aim was to identify patient and ultrasound (US) features predictive of treatment response.

MATERIALS AND METHODS

Consecutive prospectively recruited patients undergoing US-guided ICSI therapy for GTPS received baseline pre-injection questionnaires assessing pain at rest and activity, demographics and comorbidities. Baseline US and radiography findings were reported prospectively. Follow-up was performed at 6 weeks and 6 and 12 months, and change in pain scores assessed using the Wilcoxon signed rank test. Logistic regression examined associations between demographics, US findings, and a clinically significant reduction in pain score (≥50%).

RESULTS

Over 6 months, 127 patients were recruited with a median age of 63.5 years and 90% were female. The greatest pain reduction was between baseline and 6 weeks at activity (median 8 versus 5, p<0.001). The majority of patients noted a reduction in pain score, but the percentage of patients receiving a ≥50% reduction at 6 weeks, 6 months, and 12 months for pain at rest was 41%, 37%, and 36%, respectively. Regression models suggested only gluteus medius bursitis was weakly associated with pain reduction.

CONCLUSION

ICSIs confer a benefit in pain reduction to a large proportion of patients in the short term, but this may not be reduced by a clinically significant amount. This small effect size and lack of predictive imaging features suggests initial management including subsequent steroid injection could be provided without imaging guidance in the majority of cases.