A133 PORTAL VENOUS STENTING FOR THE TREATMENT OF NON-CIRRHOTIC PORTAL HYPERTENSION-RELATED GASTRIC ANTRAL VASCULAR ECTASIA: A CASE REPORT

Background

Pancreatic and hepatobiliary cancers account for 15-24% of extrahepatic portal hypertension. Treating portal hypertensive bleeding associated with these tumors has been challenging with the delayed effect of chemoradiation and patients with active bleeding being unfit for such therapies.

Portal vein stenting has been described in the literature for the treatment of variceal bleeding in such patients. We present the first report of its use for the successful treatment of refractory gastric vascular ectasia (GAVE)-related bleeding.

Purpose

To review portal vein stenting as a treatment for non-cirrhotic portal hypertension-related GAVE bleeding.

Method

Chart review was performed with the patient's informed consent.

Result(s)

A 53-year-old female patient with locally invasive pancreatic cancer presented with one week of melena and presyncope. She had a history of gastroesophageal reflux disease. Her tumor encased the celiac trunk, hepatic and splenic arteries, and abutted the superior mesenteric artery. She had been treated with chemotherapy and radiation.

On examination, she was afebrile, blood pressure was 132/87, pulse 110 beats/min, and oxygen saturation 99% on room air. Her abdomen was soft and non-tender. Her hemoglobin was 63 g/L, which represented a 64-point drop over 4 months, leukocytes 4.5 x10⁹/L, platelets 238 x10⁹/L, INR 1.1 and normal electrolytes and creatitine. Alkaline phosphatase was 399 U/L, aminotransferases normal, albumin 38 g/L and total bilirubin 6 umol/L. She was started on pantoprazole and octreotide. On admission, gastroscopy revealed copious blood in the stomach with no clear source despite gastric lavage; hemospray was applied. Given persistent bleeding, repeat gastroscopy the following day revealed 4 columns of Baveno grade III esophageal varices with no high-risk stigmata, as well as severe portal hypertensive gastropathy and GAVE. Argon plasma coagulation and esophageal banding were performed. Over the next month, she continued to have maroon-colored stools. CT angiogram revealed portal vein occlusion and contrast extravasation within the gastric lumen, in keeping with her known gastric antral bleed, with no evidence of lower gastrointestinal bleeding. She had 5 further gastroscopies where APC and GAVE banding were performed. Despite that, she developed hematemesis. Interventional radiology was consulted and performed transhepatic portal venous recanalization, angioplasty and stenting using a 10mm x 60mm self expandable nitinol stent from the superior mesenteric vein to the main portal vein. After stenting, previously seen collateral veins and cavernous transformation were significantly reduced on angiography. She was started on clopidogrel to maintain stent patency. Two days following stent insertion, she stopped clinically bleeding and her hemoglobin stabilized. She was discharged home one month later.

Conclusion(s)

In patients with GAVE-related bleeding refractory to standard therapeutics, portal venous stenting is possibly an effective treatment modality.

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Disclosure of Interest

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Advancing Early Identification of Axial Spondyloarthritis: An Interobserver Comparison of Extended Role Practitioners and Rheumatologists

OBJECTIVE

To compare clinical impression and confidence of extended role practitioners (ERP) with those of rheumatologists experienced in axial spondyloarthritis (axSpA) according to (1) evaluation of patients with chronic back pain assessed for axSpA; and (2) magnetic resonance imaging (MRI) recommendation for further investigation of these patients.

METHODS

Patients with ≥ 3 months of back pain and age of onset < 45 years were referred for axSpA evaluation. An ERP assessed consecutive patients and recorded standardized clinical information in written form. Three rheumatologists subsequently evaluated each patient based on the recorded information. Patients were classified as having axSpA or mechanical back pain based on clinical and investigative findings. Level of confidence was noted for classification and MRI indication. Agreement between assessors was evaluated using percentage agreement and κ coefficient.

RESULTS

Fifty-seven patients were assessed. Interobserver agreement of clinical impression for all raters was moderate (κ = 0.52). Agreement of clinical impression between ERP and rheumatologists ranged between 71.2% (κ = 0.41) and 79.7% (κ = 0.57). Agreement of clinical impression among rheumatologists ranged from 74.1% (κ = 0.49) to 79.7% (κ = 0.58). All rater agreement for MRI indication was fair (κ = 0.37). ERP agreement with rheumatologist for MRI recommendation ranged from 64.2% (κ = 0.32) to 75% (κ = 0.48). Agreement for MRI indication among rheumatologists ranged from 62.9% (κ = 0.27) to 74% (κ = 0.47). Confidence in clinical impression was similar among all practitioners.

CONCLUSION

ERP with specialty training in inflammatory arthritis demonstrate clinical impressions comparable with those of rheumatologists in the assessment of axSpA. Incorporation of such roles into existing models of care may assist in early detection of axSpA.

Multipotent human breast stem cell line MCF1OAT

Human breast epithelial MCF10AT cells injected with Matrigel into the subcutis of nude/beige mice form simple ducts which, with time, resemble human proliferative breast disease and sporadically progress to carcinoma. Basement membrane was visualized with a silver stain and myoepithelial cells detected by their reactivity with antibody against smooth muscle actin. The ducts formed in situ are bilayered, composed of both myoepithelial and luminal epithelial layers circumscribed by a distinct basement membrane. The human origins of both luminal and myoepithelial layers were confirmed with fluorescent in situ hybridization with a probe for human chromosome 9. Electron microscopic studies reveal actin bundles and the formation of hemidesmosomes bordering the basement membrane, consistent with myoepithelium, as well as the formation of desmosomes between luminal and myoepithelial cells.

Randomized controlled trial of virtual reality simulator training: transfer to live patients

BACKGROUND

New Residency Review Committee requirements in general surgery require 50 colonoscopies. Simulators have been widely suggested to help prepare residents for live clinical experience. We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients.

METHODS

A randomized controlled trial included general surgery and internal medicine residents with limited endoscopic experience. Following a pretest, the treatment group (n = 12) practiced on the simulator, while controls (n = 12) received no additional training. Both groups then performed a colonoscopy on a live patient. Technical ability was evaluated by expert endoscopists using previously validated assessment instruments.

RESULTS

In the live patient setting, the treatment group scored significantly higher global ratings than controls (t(22) = 1.84, P = .04). Only 2 of the 8 computer-based performance metrics correlated significantly with previously validated global ratings of performance.

CONCLUSIONS

Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls, demonstrating skill transfer to live patients. The simulator's performance metrics showed limited concurrent validity, suggesting the need for further refinement.

Heterogeneity in CBF beta/MYH11 fusion messages encoded by the inv(16)(p13q22) and the t(16;16)(p13;q22) in acute myelogenous leukemia

Inv(16)(p13q22) is one of the most frequent chromosomal rearrangements found in acute myelogenous leukemia (AML), representing approximately 16% of documented karyotypic abnormalities. The inv(16) breakpoints have been cloned and shown to involve the non-DNA binding component of the AML-1 transcription factor complex termed core binding factor beta gene (CBF beta) on 16q and the smooth muscle myosin heavy chain gene (MYH11) on 16p. In this study, we analyzed 37 cases of inv(16)-containing AML and 4 cases with t(16;16)(p13;q22) for expression of the CBF beta/MYH11 chimeric message by reverse transcription-polymerase chain reaction (PCR) analysis. CBF beta/MYH11 chimeric messages were detected in 33 of 37 cases with the inv(16) and in the 4 t(16;16)-containing cases. Sequence analysis of PCR products showed extensive breakpoint heterogeneity in both CBF beta and MYH11. In addition to the previously described breakpoint in CBF beta at nucleotide (nt) 495 (amino acid 165), we have identified a second novel fusion point at nt 399 (amino acid 133) in 7% of the cases. Similarly, a unique breakpoint site was identified in MYH11 at nt 1098, as well as at three previously characterized sites at nts 994, 1201, and 1921. Of the 4 PCR-negative cases, 2 of 3 tested lacked CBF beta rearrangements by Southern blot analysis, suggesting the possible involvement of a different genomic locus in some cases with cytogenetic evidence of inv(16). To assess whether the portions of CBF-beta contained within the CBF beta/MYH11 chimeric products retain the ability to interact with their heterodimeric DNA-binding partner AML-1, we performed in vitro DNA-binding analysis. Recombinant CBF-beta polypeptides consisting of the N-terminal 165 amino acids retained their ability to interact with AML-1, whereas mutants containing only the N-terminal 133 amino acids interacted with AML-1 less efficiently. These data suggest that different CBF beta/MYH11 products may vary subtly in their biologic activities.

Familial visceral myopathy associated with a mitochondrial myopathy

A 27 year old man with intestinal pseudo-obstruction who developed parenteral nutrition induced hyperlipidaemia and who also had ophthalmoplegia and an undifferentiated myopathy is described. Histological examination of biopsy specimens and molecular analysis show that this patient had both familial visceral myopathy and a mitochondrial myopathy, suggesting that a mitochondrial DNA mutation is the molecular lesion in familial visceral myopathy.

Methodologic advances in the cytogenetic analysis of human solid tumors

The major obstacle to successful cytogenetic analysis of human solid tumors is the acquisition of sufficient numbers of good quality metaphases for detailed cytogenetic analysis. At present, no single methodologic approach has been proven to provide successful chromosomal analysis of all human solid tumors. The technical aspects of cell culture, chromosome harvesting, and chromosome banding were the focus of considerable discussion during the First Workshop on Chromosomes in Solid Tumors. This report provides summaries of several technical protocols, emanating from several different laboratories, which have contributed to successful chromosome analysis of a variety of human solid tumors.