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.

Seizure freedom from recurrent insular low-grade glioma following laser interstitial thermal therapy

Pediatric low-grade gliomas (LGGs) are found in approximately 1-3% of patients with childhood epilepsy that is often medically refractory. Magnetic resonance guided laser interstitial thermal therapy (MRgLITT) is a minimal access technique FDA-approved since 2007 to ablate soft tissue lesions including brain tumors and seizure foci in children. The authors describe the case of an 11-year-old boy who presented with focal right-sided seizures and was found to have a growing left insular mass determined to be a WHO grade II diffuse astrocytoma. After the initial open resection using frontotemporal craniotomy with transsylvian approach, gross total resection was achieved; however, the tumor recurred, as did the seizures. Six months postoperatively, the patient underwent laser ablation with MRgLITT for the recurrent tumor with complete removal. At both 1- and 6-months post re-operation, he has remained seizure free. MRgLITT management of LGG allows for both successfully reducing tumor burden and the amelioration of secondary seizures.

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.

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.

There is no such thing like a single ACL injury: Profiles of ACL-injured patients

BACKGROUND

Current ACL registries rarely include non-operatively treated patients thus delivering an incomplete picture of the ACL-injured population. The aim of this study was to get an image of the population and treatment decision of an intrahospital registry. Our hypotheses were that patient-specific subtypes can be identified and that the percentage of operated patients differs between them.

MATERIAL AND METHODS

Three hundred and forty-six operated and non-operated patients were included from March 2011 to December 2013. Standardized questionnaires allowed for data collection on gender, age, sports practice and previous ACL injuries. Chi-square tests allowed to compare these parameters between genders and age groups. A cluster analysis was computed to determine profiles of patients with similar characteristics.

RESULTS

Three age groups were considered (I: ≤20; II: 21-35; III: ≥36 years). For males, the highest frequency of injuries was noted in group II with a greater proportion of injuries compared to females. In group III, more females were injured than males. Before injury, 54% patients were involved in competitive sports. Males were more likely to be injured in pivoting/contact sports before 35 and females during recreational skiing after 35. Twenty-one percent of the patients had had a previous ACL injury. The percentage of surgical treatment was superior to 80% in patients under 35 years involved in competitive sports, of 60-80% for those not involved in competitive sports and inferior to 60% for patients above 35 years.

DISCUSSION

Systematic data collection allowed to identify specific subtypes of ACL-injured patient according to gender, age, previous ACL injury and preinjury level of practice. The decision-making process for or against ACL reconstructions at time of presentation depended on these characteristics. Consideration of these parameters will serve as a basis for an individualized treatment approach and a better understanding of patients at risk for ACL injuries.

LEVEL OF EVIDENCE

III.

Promotion of physical activity in patients with non-communicable diseases in Luxembourg: a follow-up of the Sport-Sante inventory from 2014

Regular practice of physical activity (PA) has many health benefits in both healthy individuals and in people with non-communicable diseases (NCDs). In order to disseminate this evidence and to strengthen the promotion of PA in people with NCDs, the Sport-Santé project was created in Luxembourg and officially launched in April 2015. In 2014, a stocktaking of the different organizations offering PA for people with NCDs was realized in order to develop the Sport-Santé project. Different communication tools were used to promote Sport-Santé as well as the aforementioned organizations. The present study aimed to re-evaluate the offers of PA for people with NCDs in Luxembourg one year after the launch of the project. The organizations offering PA for people with NCDs (orthopaedics, obesity and overweight, neurology and rare diseases, oncology and cardiology) were screened in 2014 and in 2016. The number of weekly offered hours of PA for people with NCDs were collected and the participation rate was observed. Participants (192 in 2014 and 196 in 2016) volunteered to answer a survey, which contained questions regarding their age, sex, time since enrolment, travel distance, former and current PA participation, and type of recruitment. Additional items regarding prescription and refund were explored only in 2016. In 2016, more than 55 hours per week of PA were offered for people with NCDs in Luxembourg (≈44 hours per week were identified in 2014). However, this increase was not statistically significant. No difference was observed between 2014 and 2016 regarding the participation rate (2014: 8.9 ± 5.1 participants per hour; 2016: 8.4 ± 5.7 participants per hour). Participants were younger in 2016 than in 2014. The time since enrolment was shorter in 2016 than in 2014. No difference between 2014 and 2016 was observed for travel distance, sex distribution, former and current PA participation, and type of recruitment. Participants were mainly recruited by the healthcare professionals. More than 69 % of the participants would like to receive a medical prescription for the PA. Fifty-two percent of the participants would appreciate a refund of the participation fees by their health insurance. The increasing efforts of Sport-Santé and the organizations offering PA for people with NCDs lead to increase the offer. However, the participation rate remains unchanged. The decrease in age and in time since enrolment observed in 2016 could be explained by the creation of new activities, a larger participant's turnover or high number of withdrawals among long-term participants. Even if participants are mainly recruited by healthcare professionals, this type of recruitment can be attributed to very few idealists. All healthcare professionals should be aware of the offers of Sport-Santé and advise their patients to participate in a PA program. It is now time to advance the idea of prescription of PA as a privileged treatment option and to convince the policymakers to take action against sedentary behaviours in Luxembourg. Nevertheless, this type of promotion is not enough to increase the number of participants and additional strategies must be explored and developed. The best sustainable strategies are always those that approach the problem from different viewpoints.

[Benefit of skull vibration-induced nystagmus test in occupational medicine]

BACKGROUND

Nystagmus induced by vibrations (NIV), has been optimized by the present authors this last decade. The skull vibration-induced nystagmus test (SVINT) can be designated as a high-frequency global "vestibular Weber test" and can be considered as an office-based examination to detect vestibular asymmetry. The aim of this study is to define the tolerance of the SVINT as well as its comparison to the simplified caloric test of Veits (CTV) in normal workers during the pre-employment visit at the occupational medicine center.

MATERIAL AND METHODS

The vestibular function has been evaluated by the SVINT and the CTV in 87 healthy workers. The tolerance of the two procedures has been evaluated by a 4-items questionnaire (nausea, vomiting, sweating, asthenia).

RESULTS

The caloric test was normal in each worker. The SVINT was positive in one patient who had a partial unilateral vestibular dysfunction related to trauma. The mean duration of the procedure was 15 min for CTV and 1 min for SVINT. Side effects (nausea, vomiting, sweating, asthenia) were present in 50% of the workers following CTV and in only one patient after SVINT. The SVINT demonstrated significantly less side effects for each item (p < 0.0001).

CONCLUSIONS

SVINT is a valid, rapid, low-cost clinical screening test and does not cause patient discomfort. It is suggested that this test which explores vestibular high frequencies and is not modified by vestibular compensation is useful for the diagnostic screening of workers' vestibular dysfunction, when combined with other vestibular tests and complements the CTV.

[Promotion of physical activity for secondary prevention in patients with chronic diseases: the situation in the Grand-Duchy of Luxembourg]

The regular practice of physical activities has health benefits in healthy subjects (primary prevention) and in patients with non-communicable diseases (secondary prevention). This study aimed to perform a stocktaking of the physical activities programs for patients or individuals at risk in the Grand-Duchy of Luxembourg. The organizations offering therapeutic physical activities (TPA) have been investigated. Eleven groups offering TPA adapted to different non-communicable diseases were characterized by their costs, instructors, participants and potential participants. These groups were divided into five main categories: cardiology, neurology, obesity, oncology, and orthopedics. During on-site meetings, 41 professionals, 192 participants and 34 potential participants have been interviewed during the period September 2013 to April 2014. The results show that about 40 hours of TPA, 17 hours of which in cardiology, are currently proposed every week, except during school holidays. The main TPA are gymnastics, aerobics, swimming, Nordic walking, cycling, and resistance training. The national coverage is quite low, especially for obesity, neurology and orthopedics. The costs is mainly related to the human resources, the gym being often borrowed but rarely available during school holidays. Between 200 and 400 individuals participate in the TPA. The average number of participants per hour is 8.9 (± 5.1), which represents only 50% of the maximal capacity estimated by the instructors (18.0 ± 8.2 participants per hour). The recruitment process is different according to the groups but the medical doctors and the physiotherapists are mainly involved in this process. However, the majority of the potential participants were not aware of the existence of the groups. The existence of these groups is a positive point, since it contributes to compensate for the current lack of concrete action of the public and private authorities. However, the current TPA offer is clearly insufficient. The groups are frail, on the one hand because their future relies exclusively upon the idealism of a few key actors, and on the other hand because the participation rate is low. This low rate is related to a lack of information and to organizational constraints. However, the public health action initiated by these groups should be perpetuated and strengthened with a better structuration and professionalization. Finally, the increase of the number of participants remains the main objective.

On the Frequency and Amplitude Dependence of the Payne Effect: Theory and Experiments

In this paper, we develop a physical approach to represent the Payne effect which is observed in filler-reinforced elastomers. The starting point for the constitutive model is the well-known theory of linear viscoelasticity, where the stress is a linear functional of the deformation history. Since the corresponding relations are unable to describe any kind of amplitude dependence, we introduce a nonlinearity into the model. To this end, we replace the physical time, t, by a modified time scale, z, which is a functional of the deformation history. This approach was originally introduced by Valanis in the context of rate-independent plasticity and applied in a modified form; for example, by Haupt and Sedlan to represent process-dependent relaxation properties of rubber. The modified time, z, is a monotonic function of the physical time, t, and can be interpreted as an intrinsic time scale of the material. The rate of this time scale is non-negative and depends on the process history. We propose a constitutive relation for the variable z(t), which is driven by a fractional time derivative of the deformation, calculate analytical expressions for the storage and dissipation moduli and show that such phenomena as the frequency and the amplitude dependence, observed in experiments, are well represented.

Sub-acute cerebellar degeneration with anti-Yo autoantibodies: immunohistochemical analysis of the immune reaction in the central nervous system

We report the pathological findings of a woman with a sub-acute cerebellar syndrome who had undergone surgery 3 years before for endometrial carcinoma. Both serum and cerebrospinal fluid contained high titres of autoantibodies against the cytoplasm of Purkinje cells that recognized a band of 62 kDa on immunoblotting of neuronal extracted proteins (pattern anti-Yo). No tumour was found despite a full range of gynaecological investigations; the neoplastic marker CA125 was slightly elevated and oligoclonal bands were detected in the cerebrospinal fluid. The patient died from acute myocardial infarction 4 months after developing this syndrome. At autopsy, no macroscopic evidence of tumour was obtained and the brain showed no abnormalities. On microscopic examination of the central nervous system diffuse degeneration of Purkinje cells could be seen throughout the cerebellum. Immunohistochemical analysis showed a CD8 lymphocyte infiltration in the cerebellum and cerebral cortex and diffuse microglial activation throughout the brain. These cells expressed high levels of MHC-II antigens on their cell membranes. The serum autoantibodies reacted with the cytoplasm of the remaining Purkinje cells. The short interval between the onset of symptoms and death of the patient could explain the difference between our findings and those reported in the literature in which no inflammatory infiltrates were detected. The immunohistochemical findings as well as the inflammatory cerebrospinal fluid profile seen in our case seem to support the concept that in paraneoplastic cerebellar degeneration with anti-Yo antibodies, an immune mediated mechanism is responsible for the damage to the cerebellum.

[Use of tiapride in the anxious alcoholic]

The alcoholic patient is usually anxious. Anxiety is increased by withdrawal. The anxiety-relieving effect of tiapride was studied in 20 alcoholics, with a mean age of 44 years. 18 patients were male. Alcoholism was chronic in 18 cases and paroxystic in two. At the time of withdrawal each patient was given 3 intramuscular injections daily for 7 days, then 3 tablets per day. Results, which were evaluated according to the Hamilton score, were excellent in 9 cases, good in 10 and poor in 1: no failure was recorded. The symptoms which responded best were fear, somatic and psychic manifestations of anxiety, depressive feelings and sleep disturbances. Concomitantly, digestive disorders, anorexia, tremor and pain were alleviated. Tolerance was excellent: no neurologic, digestive, cardiovascular or biologic manifestations were recorded. In caring for alcoholic patients, the critical time of withdrawal is undeniably facilitated by the use of tiapride.