Another gastrointestinal lesion amendable for ablation.

A 79-year-old patient, with a history of redoendoscopic ampullectomy (low grade dysplasia), was referred to our hospital with cholestatic liver function abnormalities and dilation of the common bile duct. Diagnostic endoscopic ultrasound (EUS) was performed (Figure 1, left), as well as upper gastrointestinal endoscopy (Figure 1, right). What is the final diagnosis and which treatment would you propose?

Long-term clinical outcome after thiopurine discontinuation in elderly IBD patients.

INTRODUCTION AND AIM: Thiopurines - although used frequently in inflammatory bowel diseases (IBD) - carry a significant safety risk, particularly with prolonged use and/or in elderly patients. Stopping therapy, however, may trigger relapses. We assessed the long-term outcome of elderly IBD patients after discontinuation of thiopurine while in clinical remission. METHODS: Electronic medical records from IBD patients >60 years whoever received thiopurine treatment were reviewed. Patients who stopped thiopurine after 60 years of age while in clinical and/or endoscopic remission were included. Long-term outcomes included duration of clinical remission, time to clinical relapse, and development of malignancy. RESULTS: In total, 142 patients receiving thiopurines while they were >60 years were identified. Ninety-one patients stopped thiopurines at >60years while in clinical and/or endoscopic remission. After a median follow-up of 66 months, 28 (30.8%) developed a clinical relapse. The median duration of TP therapy in relapses was significantly shorter than in patients who remained in remission (median 45 vs. 103 months, respectively; p = .005). After relapse, 10 patients started a biological (36%) and seven received steroids (25%). Surgery was needed in 36% of patients (10/28). Overall, 26 malignancies developed. CONCLUSION: Discontinuation of TP in elderly IBD patients in clinical and/or endoscopic remission results in sustained clinical remission in two-thirds of patients. Patients who flare can mostly be rescued with biologicals although one-third necessitate surgery. A significant proportion of patients developed malignancies under but also after thiopurines discontinuation, indicating that these patients necessitate a continued close follow-up. Decision-making in this vulnerable subgroup of patients remains difficult.

Directional differences in head stabilisation in Acanthodactylus pardalis lizards.

Running inevitably causes the animal trunk to undulate. The consequential head rotations have to be stabilised in space for a steady gaze and an accurate sense of self-motion for balance. The ecology and anatomy of the species determine the necessity to stabilise the head in yaw, pitch, and roll direction. Terrestrial lizards, running with a sprawled body posture, are especially prone to undulations in the horizontal (yaw) plane. Measurements on an experimental oscillation platform show that Acanthodactylus pardalis lizards stabilise their head less in pitch direction (54% stabilisation) than in yaw and roll direction (66% and 64% stabilisation, respectively). Because we performed these experiments in darkness, the lizards based their head stabilisation on vestibular information. Hence, we hypothesised that their vestibular system is less sensitive in pitch direction than in yaw and roll direction. Yet, this was not confirmed by a detailed Fluid-Structure Interaction model of the membranous labyrinth, which showed that not pitch sensitivity (88% of yaw sensitivity), but roll sensitivity (73% of yaw sensitivity) is the lowest. So why is the head stabilisation in darkness almost as good in roll direction as in yaw direction? While this may be due to neurological nonlinearities, it seems worth noticing that the moment of inertia is lowest in roll direction due to the elongated head shape. Hence, less torque is needed to stabilise a head rotation in roll direction than in the other two directions.