Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

William H. Feindel (1918-2014)

William Howard Feindel (1918-2014) was one of the world's most distinguished neurosurgeons and a brilliant neuroscientist. As the Montreal Neurological Institute's third director, having succeeded Theodore Rasmussen and Wilder Penfield, he proved to be a visionary medical and scientific administrator. His keen interests in epilepsy and brain imaging were enhanced by a passion for medical history. Students and young people invariably gravitated to Dr. Feindel; he was a kind, patient, thoughtful, intelligent, and caring mentor who was never too busy for them. A pioneer in his own right, Dr. Feindel linked our modern neurosurgical world with the legacy of the first generations of important neurosurgeons and neuroscientists.

Communicating hydrocephalus and vestibular schwannomas: etiology, treatment, and long-term follow-up

Background Large vestibular schwannomas (VSs) can cause hydrocephalus by obstructing the fourth ventricle. Little is known about the communicating hydrocephalus that is seen with a smaller VS. Methods The clinicopathological findings and follow up of three patients with communicating hydrocephalus associated with a small VS are presented. Results Four patients aged 40 to 66 years (mean: 57.7) presented with ataxia, dementia, and urinary incontinence. The VS were 2.0 to 2.4 cm. The cerebrospinal fluid (CSF) protein was elevated in three patients in whom it was measured (1.7 to 6 times normal). The VS was resected in two patients. All of the patients required ventriculoperitoneal shunting (VPS). All of the patients were asymptomatic or improved at follow-up at 9 months to 13 years. Conclusion Communicating hydrocephalus associated with a VS can occur in younger patients than was previously thought. An elevated CSF protein appears to be important, but other factors may be involved. A shunting procedure is often required to relieve the symptoms of hydrocephalus even if the tumor is resected. Possible etiological causes of communicating hydrocephalus in patients with a small VS are discussed.

Low-grade oligodendroglioma: an indolent but incurable disease? Clinical article

OBJECT

The authors reviewed their institutional experience with pure low-grade oligodendroglioma (LGO), correlating outcomes with several variables of possible prognostic values.

METHODS

Sixty-nine patients with WHO-classified LGOs were treated between 1992 and 2006 at the McGill University Health Center. Clinical, pathological, and radiological records were carefully reviewed. Demographic characteristics; the nature and duration of presenting symptoms; baseline neurological function; extent of resection; Karnofsky Performance Scale score; preoperative radiological findings including tumor size, location, and absence/presence of enhancement; and pathological data including chromosome arms 1p/19q codeletion and O-methylguanine-DNA methyltransferase promoter gene methylation status were all compiled. The timing and dose of radio- and/or chemotherapy, date of tumor progression, pathological finding at disease progression, treatment at time of disease progression, and status at the last follow-up were also recorded.

RESULTS

The median follow-up period was 6.1 years (range 1.3-16.3 years). The majority (78%) of patients presented with seizures; contrast enhancement was initially seen in 16 patients (25%). All patients had undergone an initial surgical procedure: gross-total resection in 27%, partial resection in 59%, and biopsy only in the remaining 13%. Fifteen patients received adjuvant radiotherapy. Data on O-methylguanine-DNA methyltransferase promoter gene methylation status was available in 47 patients (68%) and in all but 1 patient for 1p/19q status. Survival at 5, 10, and 15 years was 83, 63, and 29%, respectively. Multivariate analysis showed that seizures at presentation and the absence of contrast enhancement were the only independent favorable prognostic factors for survival. The 5-, 10-, and 15-year progression-free survival rates were 46, 7.7, and 0%, respectively.

CONCLUSIONS

This retrospective review confirms the indolent but progressively fatal nature of LGOs. Contrast enhancement was the most evident single prognostic factor. New treatment strategies are clearly needed in the management of this disease.

Epilepsy surgery: historical highlights 1909-2009

This review focuses on some historical highlights of the surgery of epilepsy, beginning with the reports of Horsley, Krause, and Cushing to which appeared in 1909, the year that The International League Against Epilepsy (ILAE) was inaugurated. We then outline key contributions from Europe and North America, and examine particularly the evolution of our understanding of temporal lobe seizures, which have now become the most common form of epilepsy amenable to surgical cure.

Prospective serial proton MR spectroscopic assessment of response to tamoxifen for recurrent malignant glioma

OBJECTIVE

Early prediction of imminent failure during chemotherapy for malignant glioma has the potential to guide proactive alterations in treatment before frank tumor progression. We prospectively followed patients with recurrent malignant glioma receiving tamoxifen chemotherapy using proton magnetic resonance spectroscopic imaging ((1)H-MRSI) to identify intratumoral metabolic changes preceding clinical and radiological failure.

METHODS

We performed serial (1)H-MRSI examinations to assess intratumoral metabolite intensities in 16 patients receiving high-dose oral tamoxifen monotherapy for recurrent malignant glioma (WHO grade III or IV) as part of a phase II clinical trial. Patients were followed until treatment failure, death, or trial termination.

RESULTS

Patients were officially classified as responders (7 patients) or non-responders (9 patients) 8 weeks into treatment. At 8 weeks, responders and non-responders had different intratumoral intensities across all measured metabolites except choline. Beyond 8 weeks, metabolite intensities remained stable in all responders, but changed again with approaching disease progression. Choline, lipid, choline/NAA, and lactate/NAA were significantly elevated (P < 0.02), while creatine (P < 0.04) was significantly reduced, compared to stabilized levels on average 4 weeks prior to failure. Lactate was significantly elevated (P = 0.036) fully 8 weeks prior to failure. In one patient who was still responding to tamoxifen at the conclusion of the trial, metabolite intensities never deviated from 8-week levels for the duration of follow-up.

CONCLUSIONS

Characteristic global intratumoral metabolic changes, detectable on serial (1)H-MRSI studies, occur in response to chemotherapy for malignant glioma and may predict imminent treatment failure before actual clinical and radiological disease progression.

Multimodal multidisciplinary surgical approach for the treatment of pituitary tumours

OBJECTIVES

The surgical management of pituitary tumours is being impacted by the development of two key technologies: image guidance and endoscopy. This study sought to assess their impact.

METHODS

Retrospective review of all patients referred to the Skull Base Clinic of the McGill University Health Centre since 2000. Patients were operated on in a multidisciplinary context using a multimodal approach combining endoscopy and microscopy. Imaging during the surgery was initially supported by both three-dimensional neuronavigation and traditional C-arm fluoroscopy.

RESULTS

Seventy-five patients were referred to the multidisciplinary clinic, for a total of 41 surgeries. Neuronavigation was used in all cases. C-arm fluoroscopy was not found to improve our surgeries and was removed from our protocol. Endoscopy was found to be advantageous as it allowed improved visualization. It also permitted identifying surrounding structures in the lateral wall of the sphenoid sinus, next to the tumour, and "around corners." Moreover, it encouraged multidisciplinary co-operation as it allowed neurosurgeons and otolaryngologists to follow progress during the case. Nevertheless, the microscope continued to play a role as it facilitated a bimanual technique, stable magnification, and a three-dimensional view. Morbidities in our case series appeared to be minimal.

CONCLUSION

Both endoscopy and the microscope were found to have a role in our surgeries. We consider these technologies to be complementary. C-arm fluoroscopy was rendered obsolete by the neuronavigation unit. A multidisciplinary, multimodal approach maximizes the benefits of these new technologies and permits the best surgical result.

Corporate governance research on the free web: a selected annotated guide

Purpose

The web offers a large and ever expanding range of information sources on the popular and widely researched topic of corporate governance. This paper aims to introduce keys sites of quality and relevance to those interested in researching the field of corporate governance using freely available web resources. It will also aims to prove useful to librarians who wish to develop web‐based subject pathfinders in this field or who want simply to connect with and build their knowledge of major topics and participants in the field of corporate governance.

Design/methodology/approach

By way of introduction important or groundbreaking works in the corporate governance literature are identified and cited in the paper to place selected web sites within the context of recent and historic developments in the area of corporate governance. A wide range of web‐based sources were consulted and critically evaluated in the study.

Findings

The result of this work is a significant sampling of quality web‐based information sources with evaluative annotations.

Originality/value

Given the recent explosion in information resources available on the topic of corporate governance, this paper will prove especially timely and useful to anyone interested in accessing and interacting with quality information on the free web from a wide range of significant players and stakeholders in the corporate governance arena.

Hypofractionated stereotactic radiotherapy for low grade glioma at McGill University: long-term follow-up

Small, well-defined, unresectable low-grade gliomas are attractive targets for stereotactic irradiation. Fractionated stereotactic irradiation of these targets has the theoretical benefit of increased normal tissue sparing beyond that provided by the physical characteristics of stereotactic radiosurgery. From July 1987 to November 1992, 21 patients were treated for low-grade glioma at our institution using a hypofractionated regimen of stereotactic radiotherapy. All patients had well-circumscribed, < 40 mm tumors. No patient had had prior radiotherapy. All lesions were histologically proven WHO grade I or II glial tumors. Lesions involved sensitive brain structures and were deemed unresectable. A typical dose of 42 Gy was delivered in 6 fractions over a two-week period using rigid immobilization and a linac-based dynamic stereotactic radiosurgical technique. Patients had a median age of 23 years (9-74) and were predominantly female (60%). Median tumor diameter was 20 mm. With a median follow-up for living patients of 13.3 years, the actuarial 5, 10, and 15-year overall survival rates are 76%, 71%, and 63%, respectively. Treatment was acutely well tolerated although three patients experienced late post-therapy complications. Our results and those of 241 patients treated in nine other institutional series are reviewed. Despite some examples of favorable short-term outcomes, all reported series are highly selected and thus likely biased. The data regarding the use of SRS is limited and, in our opinion, insufficient to claim a clear therapeutic advantage to SRS in the initial management of low-grade glioma. Our own results with hypofractionated stereotactic radiotherapy are similar to those expected with standard therapy.

Influence of RANTES, SDF-1 and TGF-beta levels on the value of interleukin-7 as a predictor of virological response in HIV-1-infected patients receiving double boosted protease inhibitor-based therapy

OBJECTIVES

Interleukin-7 (IL-7), RANTES (regulated on activation, normal T cell expressed and secreted), stromal cell-derived factor-1 (SDF-1) and transforming growth factor-beta (TGF-beta) appear to share certain biological properties in vitro and all are involved in HIV-1 disease progression. Our earlier observations indicated that IL-7 levels decrease upon CD4 T-cell recovery and represent a new, independent predictor of virological response. Here, we examine associations among circulating levels of IL-7, RANTES, SDF-1 and TGF-beta in hopes of gaining insight into their contribution to the predictive value of IL-7.

METHODS

Levels of IL-7, RANTES, SDF-1 and TGF-beta, and immune and viral parameters were assessed in HIV-1-infected patients.

RESULTS

Cross-sectional (n=148) and longitudinal (n=36) analyses showed that levels of IL-7, but not RANTES, SDF-1 or TGF-beta, were increased in HIV-1-infected adults compared with those of healthy controls. In the cross-sectional study, levels of IL-7 were correlated with RANTES (r=0.31, P=0.002) and TGF-beta (r=0.53, P<0.001) but not with SDF-1 (r=0.12, P=0.22), and these associations were more pronounced in patients with CD4 T-cell counts >200 cells/microL. In contrast to IL-7, levels of RANTES, SDF-1 and TGF-beta were not correlated with CD4 T-cell counts. Longitudinal analysis revealed a marked decline in IL-7 levels accompanied by an increase in CD4 T-cell count following antiretroviral therapy (ART), but no changes in RANTES, SDF-1 or TGF-beta levels. Multivariate regression analysis showed no influence of baseline RANTES, SDF-1 or TGF-beta levels on the value of IL-7 as a predictor of virological response at 48 weeks.

CONCLUSIONS

Collectively, these results indicate that changes in IL-7 levels did not induce changes in RANTES, SDF-1 or TGF-beta. Furthermore, they indicate that RANTES, SDF-1 or TGF-beta levels do not explain the predictor value of IL-7 in patients receiving ART.

Psychologic distress in postmyocardial infarction patients who have returned to work

OBJECTIVE

To assess the prevalence of psychologic distress in women and men returning to work after a myocardial infarction (MI) and to compare this prevalence with the prevalence observed among men and women of the general working population.

METHODS

The study population was composed of 990 post-MI patients (106 women and 884 men) recruited in 30 hospitals who had returned to work after their first MI. Psychologic distress was measured with the French version of the Psychiatric Symptom Index (PSI). Adjusted mean PSI score and prevalence of psychologic distress were compared with those observed in 8829 other workers (3823 women and 5006 men), representative of the general working population.

RESULTS

Mean PSI score was higher in post-MI women (30.3) than in post-MI men (20.3). This score was also higher in the post-MI population than in the general working population, both for women (30.3 compared with 17.0) and men (20.3 compared with 14.1). Psychologic distress was more prevalent in post-MI women than in post-MI men (prevalence ratio [PR], 1.62; confidence interval [CI], 1.27-2.07). This score was also higher in post-MI women and post-MI men than in the general working population (PR, 2.18; CI, 1.75-2.71 and 1.76; CI, 1.48-2.08, respectively).

CONCLUSIONS

Among the presumably fittest post-MI patients, namely those who had returned to work, psychologic distress was significantly more prevalent than in the general working population, particularly among women. Further research is needed to shed light on prognosis in post-MI workers experiencing psychologic distress and on adequate intervention before and after their return to work.

The use of hypofractionated intensity-modulated irradiation in the treatment of glioblastoma multiforme: preliminary results of a prospective trial

PURPOSE

Despite major advances in treatment modalities, the prognosis of patients with glioblastoma multiforme (GBM) remains poor. Exploring hypofractionated regimens to replace the standard 6-week radiotherapy schedule is an attractive strategy as an attempt to prevent accelerated tumor cell repopulation. There is equally interest in dose escalation to the gross tumor volume where the majority of failures occur. We report our preliminary results using hypofractionated intensity-modulated accelerated radiotherapy regimen in the treatment of patients with GBM.

METHODS AND MATERIALS

Between July 1998 and December 2001, 25 patients with histologically proven diagnosis of GBM, Karnofsky performance status > or =60, and a postoperative tumor volume < or =110 cm3 were treated with a hypofractionated accelerated course of radiotherapy. The gross tumor volume (GTV) was defined as the contrast-enhancing lesion on the postoperative MRI T1-weighted images with the latter fused with computed tomography images for treatment planning. The planning target volume was defined as GTV + 1.5-cm margin. Using forward-planning intensity modulation (step-and-shoot technique), 60 Gy in 20 daily fractions of 3 Gy each were given to the GTV, whereas the planning target volume received a minimum of 40 Gy in 20 fractions of 2 Gy each at its periphery. Treatments were delivered over a 4-week period using 5 daily fractions per week. Dose was prescribed at the isocenter (ICRU point). Three beam angles were used in all of the cases.

RESULTS

Treatments were well tolerated. Acute toxicity was limited to increased brain edema during radiotherapy in 2 patients who were on tapering doses of corticosteroids. This was corrected by increasing the steroid dose. At a median follow-up of 8.8 months, no late toxicity was observed. One patient experienced visual loss at 9 months after completion of treatment. MRI suggested nonspecific changes to the optic chiasm. On review of the treatment plan, the total dose to the optic chiasm was confirmed to be equal to or less than 40 Gy in 20 fractions. When Radiation Therapy Oncology Group recursive partitioning analysis was used, 10 patients were class III-IV, and 15 patients were class V-VI. To date, 21 patients have had clinical and/or radiologic evidence of disease progression, and 16 patients have died. The median survival was 9.5 months (range: 2.8-22.9 months), the 1-year survival rate was 40%, and the median progression-free survival was 5.2 months (range: 1.9-12.8 months).

CONCLUSION

This hypofractionated accelerated irradiation schedule using forward planning (step-and-shoot) hypofractionated, intensity-modulated accelerated radiotherapy is feasible and seems to be a safe treatment for patients with GBM. A 2-week reduction in the treatment time may be of valuable benefit for this group of patients. However, despite this accelerated regimen, no survival advantage has been observed.

Proton magnetic resonance spectroscopic imaging can predict length of survival in patients with supratentorial gliomas

OBJECTIVE

We compared the ability of proton magnetic resonance spectroscopic imaging ((1)H-MRSI) measures with that of standard clinicopathological measures to predict length of survival in patients with supratentorial gliomas.

METHODS

We developed two sets of leave-one-out logistic regression models based on either 1) intratumoral (1)H-MRSI features, including maximum values of a) choline and b) lactate-lipid, c) number of (1)H-MRSI voxels with low N-acetyl group values, and d) number of (1)H-MRSI voxels with high lactate-lipid values, all (a-d) of which were normalized to creatine in normal-appearing brain, or 2) standard clinicopathological features, including a) tumor histopathological grade, b) patient age, c) performance of surgical debulking, and d) tumor diagnosis (i.e., oligodendroglioma, astrocytoma). We assessed the accuracy of these two models in predicting patient survival for 6, 12, 24, and 48 months by performing receiver operating characteristic curve analysis. Cox proportional hazards analysis was performed to assess the extent to which patient survival could be explained by the above predictors. We then performed a series of leave-one-out linear multiple regression analyses to determine how well patient survival could be predicted in a continuous fashion.

RESULTS

The results of using the models based on (1)H-MRSI and clinicopathological features were equally good, accounting for 81 and 64% of the variability (r(2)) in patients' actual survival durations. All features except number of (1)H-MRSI voxels with lactate-lipid/creatine values of at least 1 were significant predictors of survival in the (1)H-MRSI model. Two features (tumor grade and debulking) were found to be significant predictors in the clinicopathological model. Survival as a continuous variable was predicted accurately on the basis of the (1)H-MRSI data (r = 0.77, P < 0.001; median prediction error, 1.7 mo).

CONCLUSION

Our results suggest that appropriate analysis of (1)H-MRSI data can predict survival in patients with supratentorial gliomas at least as accurately as data derived from more invasive clinicopathological features.

2-Methoxyestradiol overcomes drug resistance in multiple myeloma cells

2-Methoxyestradiol (2ME2) an estrogen derivative, induces growth arrest and apoptosis in leukemic cells and is also antiangiogenic. In this study, we demonstrate that 2ME2 inhibits growth and induces apoptosis in multiple myeloma (MM) cell lines and patient cells. Significantly, 2ME2 also inhibits growth and induces apoptosis in MM cells resistant to conventional therapies including melphalan (LR-5), doxorubicin (Dox-40 and Dox-6), and dexamethasone (MM.1R). In contrast to its effects on MM cells, 2ME2 does not reduce the survival of normal peripheral blood lymphocytes. Moreover, 2ME2 enhances Dex-induced apoptosis, and its effect is not blocked by interleukin-6 (IL-6). We next examined the effect of 2ME2 on MM cells in the bone marrow (BM) milieu. 2ME2 decreases survival of BM stromal cells (BMSCs), as well as secretion of vascular endothelial growth factor (VEGF), and IL-6 triggered by the adhesion of MM cells to BMSCs. We show that apoptosis induced by 2ME2 is mediated by the release of mitochondrial cytochrome-c (cyto-c) and Smac, followed by the activation of caspases-8, -9, and -3. Finally, 2ME2 inhibits MM cell growth, prolongs survival, and decreases angiogenesis in a murine model. These studies, therefore, demonstrate that 2ME2 mediates anti-MM activity directly on MM cells and in the BM microenvironment. They provide a framework for the use of 2ME2, either alone or in combination with Dex, to overcome drug resistance and to improve outcome in MM.

Acoustic neuroma: outcome study

Three therapeutic modalities have been advocated in the management of acoustic neuromas: observation, surgery, and radiosurgery. Although surgery is still considered conventional treatment, at times the management can be controversial. The objectives of this article are to assess the results of each of these treatment modalities in a tertiary care acoustic neuroma referral setting. The methodology chosen was to group the patients along the initial intent to treat and then to see the results obtained. A total of 51 patients followed in the Skull Base Clinic of the McGill University Health Centre were included. The intent to treat was as follows: observation, 22 patients; surgery, 26 patients; and radiosurgery, 3 patients. The results showed that 50% of those followed by observation demonstrated growth and required surgery or radiotherapy. Surgical results, in terms of facial nerve outcome, varied with tumour size but also improved dramatically with the introduction of facial nerve monitoring and a multidisciplinary approach. In small and medium-size tumours (< 30 mm), intent to treat by observation or by surgery (with intraoperative monitoring) yielded similar results. The limitations of this study are discussed. In the future, a prospective multicentric study may help better in assessing the value of the various management options.