High-quality data remains scarce in terms of optimal management strategies in the elderly inflammatory bowel disease (IBD) population. Indeed, available trials have been mostly retrospective, of small sample size, likely owing to under-representation of such a population in the major randomized controlled trials. However, in the last five years, there has been a steady increase in the number of published trials, helping clarify the estimated benefits and toxicity of the existing IBD armamentarium. In the Everhov trial, prescription strategies were recorded over an average follow-up of 4.2 years. A minority of elderly IBD patients (1%-3%) were treated with biologics within the five years following diagnosis, whilst almost a quarter of these patients were receiving corticosteroid therapy at year five of follow-up, despite its multiple toxicities. The low use of biologic agents in real-life settings likely stems from limited data suggesting lower efficacy and higher toxicity. This minireview will aim to highlight current outcome measurements as it portends the elderly IBD patient, as well as summarize the available therapeutic strategies in view of a growing body of evidence.

gastrointestinal activity in myxoedema-from chronic constipation to the most severe ileus-has been reported. The milder forms are reversible with thyroid hormone replacement, but more severely affected patients die of other complications of hypothyroidism before treatment has had time to be effective. Only one other report2 has attributed death to the ileus.The pathological findings in our case suggest that the ileus was due to a peripheral neuropathy affecting the gut. Myxoedema is known to be associated with a polyneuropathy,3 the changes in peripheral nerves suggesting that Schwann cell disease, possibly caused by mucopolysaccharide deposition, is partly or wholly responsible for the disorder. Although no mucopolysacchardie was found in this case, Byrom4 showed that it disappears within days of thyroid hormone administration. The axons, however, were abnormal, showing a severe autonomic neuropathy affecting mainly the extrinsic nerves in the colon, but also suggesting intrinsic nerve involvement.That peripheral neuropathy can affect the alimentary canal as well as the limbs is well recognised, as in diabetes mellitus.5 Anatomical changes in bowel innervation are in fact common, but clinical symptoms are rare, probably because slight changes in the nerve supply to the limbs are enough to produce parasthesiae, but to produce a megacolon damage has to be almost complete. The pathological changes in this case suggest that the ileus might have been reversible with thyroid hormone replacement had the patient survived. Veurology, 1970, 29, 631. 4 Byrom, F B, Clinical Science, 1933-34, 1, 273. 5Smith, B,Journal ofNeurology, Neurosurgery, and Psychiatry, 1974,37, 1151 ( Case report A 70-year-old man with an eight-year history of diabetes mellitus presented with gangrene of the left foot. Conservative treatment was unsuccessful and a below-knee amputation was subsequently performed. On examination he was mildy obese and appeared hypogonadal with a high-pitched voice, a eunuchoidal habitus (span 187 cm, height 174 cm, and upper:lower segment ratio of 0-8:1), smooth skin, and fine, soft, facial hair. There was bilateral (2 2 cm) gynaecomastia, body hair was sparse, both testes were soft (1 0 5 cm), and his penis was 5 cm in length (stretched). Visual fields and sense of smell were unimpaired. There were signs of peripheral vascular disease in the right leg but no carotid bruits were present. The fundi were not seen owing to bilateral cataracts. On direct questioning he said that he had developed only a small amount of pubic and axillary hair in his teenage years and that he had never shaved. There was no family history of endocrinopathy.A clinical diagnosis of Klinefelter's syndrome was confirmed by a positive buccal smear and a karyotype of 47,XXY from peripheral blood. The serum testosterone level was 1 04 nmoll/ (0 29 ng/ml), serum LH <25 ,ug LER907j1, and serum FSH 230 ,tg LER-907, 1. A luteinising hormone-releasing hormone (LHRH) test showed normal FSH and LH responses (see table). A thyrotrophin-releasing horm...

Haemophagocytic lymphohistiocytosis (HLH) causing multiorgan failure has been reported as an acute clinical presentation of COVID-19. However, the literature surrounding HLH in the context of a postacute COVID-19 syndrome is limited. This report presents a case of a life-threatening HLH occurring 6 weeks after a pauci-symptomatic COVID-19 infection in a previously healthy adult. A bone marrow aspirate confirmed the HLH and the patient was successfully treated with dexamethasone and etoposide. To our knowledge, this is the first case of HLH occurring as a postacute COVID-19 syndrome following a pauci-symptomatic initial infection.

Pulmonary tumor embolism (PTE) is a rare manifestation of cancer. It is characterized by the presence of tumor cell emboli in the pulmonary arterioles and capillaries leading to an elevation of pulmonary vascular resistance. The ante-mortem diagnosis is difficult. We report a case of PTE associated with recurrent breast cancer that presented with neurological symptoms due to paradoxical cerebral embolism.

Background Anticoagulants are a leading cause of morbidity among hospitalized patients, with prescription errors commonly reported. Literature surrounding anticoagulation stewardship is scarce despite its documented effectiveness in the antimicrobial realm. Objective To determine the proportion of accepted recommendations on inappropriate anticoagulant prescriptions suggested by a multidisciplinary anticoagulation stewardship program (ASP). Methods We conducted a descriptive cohort study of hospitalized patients using therapeutic anticoagulation at a large Canadian tertiary care center between September 1, 2019, and February 28, 2020. A multidisciplinary ASP, composed of physicians and pharmacists, was implemented on June 1, 2019. Patient‐, anticoagulant‐, and admission‐related characteristics were collected. The primary outcome was the proportion of accepted ASP team recommendations by the prescribing team. Results A total of 381 patients were enrolled during the study period, resulting in 553 anticoagulant reviews (1.56 reviews/patient) by the ASP. The most common indications for anticoagulation were atrial fibrillation (n = 276, 72%) and venous thromboembolism (n = 84, 22%). Direct oral anticoagulants were most frequently prescribed (n = 253, 67%), followed by vitamin K antagonists (n = 88, 23%). Among the reviewed prescriptions, 355 of 553 (64%) generated a recommendation; 299 of 355 (84%) recommendations were accepted by the treating team. Dose adjustments were the leading category of recommendations (31%), followed by alerts regarding drug interactions (19%). Conclusion Inpatient anticoagulant prescriptions were optimized following recommendations by the ASP team. The most frequent types of prescription changes concerned dose adjustments and drug interactions. Further research is required to assess the effect of an ASP on clinical outcomes.

Esophageal squamous cell carcinoma (ESCC) is recognized as one of the most lethal malignancies worldwide. The disease's tendency to quickly metastasize precludes many patients from receiving curative therapy. The most common sites of distal metastases include the liver, lungs, bones, and brain. We report a case of ESCC metastasizing to the rectosigmoid region years after treatment with neoadjuvant chemoradiation and esophagectomy. To our knowledge, only a handful of cases of ESCC with colonic metastases have been previously documented.

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