Acute Thrombosis of an Aneurysm of the Small Saphenous Vein: A Case Report

BACKGROUND

A venous aneurysm (VA) is a focal dilatation of a nonvariceal vein (diameter increased by at least 1.5 times compared to the adjacent upstream or downstream venous segment), which carries a risk of venous thromboembolism (VTE) when located in the deep veins of the lower limbs but also when it affects the veins above the muscle fascia.

CASE

We report the case of a 40-year-old woman who presented with a painful and disabling mass-like lesion of the upper third of the right calf. A Doppler ultrasound (DUS) examination revealed a small saphenous vein (SSV) dilated at the saphenopopliteal junction (SPJ) and thrombosed along its entire length. Anticoagulant treatment was initiated but although the thrombosis regressed on DUS, the functional impotence and the persistence of pain prompted a stripping of the SSV. Histology allowed the diagnosis of SSV's primary aneurysm.

DISCUSSION

Dilated segments of the saphenous vein are not always varicose veins (VVs). True VAs can develop on veins located above the muscular fascia and, like deep VAs, may trigger VTE. Small saphenous vein aneurysms have seldom been reported, and only a few clinical observations have described the thrombosis of a SSV aneurysm. Any mass in the popliteal fossa or upper part of the calf should be examined by DUS to look for an SSV aneurysm. Excision of the saphenous vein with junctional ligation is advised if thrombosis is present at the time of diagnosis.

Bilateral superficial temporal vein thrombosis after acute carbon monoxide poisoning and prolonged immobilisation: a case report

A prolonged stay on the ground after acute carbon monoxide poisoning (COP) is a high-risk situation for venous thromboembolism (VTE), but unusual-site venous thrombosis is rare in this setting. An 81-year-old woman with no personal or family history of VTE who lied on the ground for several hours following massive COP had painful and oedematous temples, so a Doppler ultrasound was prompted and revealed a bilateral superficial temporal vein (STV) thrombosis. There was no heart failure, trauma, inflammatory disease, infection, or vascular malformation. The thrombosis regressed on fondaparinux 2.5 mg given as a daily subcutaneous injection for 45 days. Our observation emphasizes the need to look not only for arteritis but also for venous thrombosis before any temporal pain. STV thrombosis has been reported four times to date. We report the first case of bilateral STV thrombosis in the setting of massive COP and prolonged immobilisation in an elderly patient.

[Succès de traitement par Cabergoline d'une série de cas de cardiomyopathie du péripartum, incluant un cas critique nécessitant une assistance circulatoire mécanique]

Peripartum cardiomyopathy is a life-threatening condition that requires urgent diagnosis and management. Bromocriptine was established as disease specific therapy; less data is known about Cabergolin which is another prolactin secretion inhibitor. In this paper we report 4 peripartum cardiomyopathy cases treated successfully with Cabergoline, including a cardiogenic shock case requiring mechanical circulatory support.

Coronary-subclavian steal syndrome causing myocardial infarction after arteriovenous fistula creation: a case report

Coronary subclavian steal syndrome (CSSS) caused by left subclavian artery (LSA) stenosis is a rare cause of myocardial infarction in patients having coronary artery bypass grafting (CABG), and it has also been observed after an arteriovenous fistula (AVF) was made. A 79-year-old woman who had undergone CABG years earlier and an AVF creation 1 month before experienced a non-ST-elevation myocardial infarction (NSTEMI). While selective catheterization of the left internal thoracic artery graft was impossible, a computed tomography scanner showed patency of all bypasses and proximal subocclusive LSA stenosis, and the digital blood pressure measurements objectified a haemodialysis-induced distal ischaemia. LSA's angioplasty and covered stent placement were successfully performed, resulting in symptom remission. A CSSS-induced NSTEMI due to a LSA stenosis aggravated by a homolateral AVF several years after CABG has been documented only infrequently. If vascular access is required in the presence of CSSS risk factors, the contralateral upper limb should be preferred.

Upper-limb acute superficial lymphatic thrombosis: A case report

Upper‐limb acute superficial lymphatic is a rare phenomenon that has received little attention in the medical literature to date, yet it mimics superficial venous thrombosis and may also complicate a skin punch biopsy.

Rapidly spreading deep dissecting hematoma occurring 1 month after a minor trauma: A case report

A deep dissecting hematoma is the most serious complication of dermatoporosis, consisting of a rapidly expanding blood collection that splits the hypodermis from the muscle fascia. A several-week time lapse between a minor trauma-induced superficial hematoma and its sudden evolution into a rapidly spreading deep dissecting hematoma is unusual. We report the case of a 70-year-old woman with long-term oral anticoagulation and dermatoporosis who suddenly developed a rapidly spreading right-leg deep dissecting hematoma 1 month after minor trauma, for which a surgical debridement and drainage were performed. Only local care and absorbent dressings were used to manage the post-operative wound, and within 4 months, the wound had healed. In this report, we emphasize the importance of preventing deep dissecting hematoma in patients who are at risk as well as the need to weigh the benefits and risks of anticoagulants when dermatoporosis cutaneous signs are present. A limb-threatening deep dissecting hematoma may develop suddenly, even weeks after a minor impact. In order to prevent skin necrosis from occurring, caregivers, patients, and carers must be able to identify this condition early on.

The Lebanese left ventricular assist device experience, a success story despite the odds

BACKGROUND AND AIM

Heart failure is still a leading cause of mortality and morbidity. Assist devices are reserved for advanced heart failure patients with no other therapeutic options. We aim in this paper to describe the characteristics and outcome of Lebanese left ventricular assist device (LVAD) patients.

RESULTS

From 2010 till December 2019, 78 patients were implanted with assist devices at the Beirut cardiac Institute, 82 pumps were used. To the most recent follow up after 10 years, 26 patients died (34%). 24 patients of 35 (68%) survived more than 5 years. Seven patients only (9%) died during one month of surgery. One year mortality was 19% (15 patients). The leading cause of early mortality was infection, whereas cerebrovascular accidents CVA were the leading cause of late mortality. Pump thrombosis occurred in 12% of the cases. The most serious long term complication was haemorrhagic CVA. Only seven patients (9%) received heart transplantation, with a mean time on support prior to transplantation of 1303 ± 213 days.

CONCLUSION

In this manuscript we reported the characteristics and outcome of the largest population of LVAD patients in Lebanon. The survival rate was 81% at one year. These findings were comparable to the international registries except for rates of heart transplantation. More efforts should be made to encourage organ donation in Lebanon.

Right ventricle failure in patients treated with left ventricular assist device

This review article aim to highlight the right ventricular function peri left ventricular assist device implantation, and to assess the incidence, physiopathology, predictors, management and prognosis, of right ventricular failure post-implant.

Abstract P3-07-11: Inhibition of Pin1 or CDK-mediated Smad3 phosphorylation reduces triple negative breast cancer cell EMT, migration and invasion

Introduction: Triple negative breast cancer (TNBC) is an aggressive subtype associated with poor outcomes. Accordingly, there is an urgent need to develop novel and targeted therapeutics for patients with this disease subtype. Cyclins D and E and the corresponding activation of CDK4/2 represent promising therapeutic targets for the treatment of TNBC. CDK4/2 can non-canonically phosphorylate Smad3, a key TGFβ signaling intermediate, and this phosphorylation is associated with the promotion of cell migration and EMT in cyclin-overexpressing breast cancers. Additionally, CDK-mediated Smad3 phosphorylation facilitates an interaction between Smad3 and Pin1. Pin1 is a cis-trans isomerase that is also overexpressed in aggressive breast cancers and can enable TNBC cell migration. Based on these findings, we hypothesized that blockade of the CDK-mediated Smad3-Pin1 interaction, either through inhibition of Pin1 or CDK-mediated Smad3 phosphorylation, would abrogate TNBC cell migration and invasion.

Methods: Pin1 expression was knocked-down (KD) in MDA-MB-231, MDA-MB-436, and Hs578T TNBC cells by transfection with Pin1-targeting siRNA (siPin1) or control non-specific siRNA (siNS). KD efficiency was confirmed with immunoblotting. Pin KD/TNBC cell migration and invasion assays were performed on uncoated or Matrigel-coated trans-wells, respectively. Media containing 10% FBS was used as a chemoattractant. Following Pin1 KD, immunoblotting was used to evaluate EMT-associated protein expression. To inhibit CDK-mediated Smad3 phosphorylation, TNBC cells were treated with 600 nM of CDK2 inhibitor (CDK2i) for 72 hours. Immunoblotting was then performed to determine Smad3 phosphorylation and EMT-associated protein expression. Co-immunoprecipitation assays were used to examine the impact of CDK2i treatment on the Smad3-Pin1 interaction. Finally, following CDK2i treatment, assays were performed to determine the ability of TNBC cells to migrate and invade.

Results: KD of Pin1 expression in TNBC cells resulted in a decrease in cell migration and invasion when compared to control cells in all the study cell lines. This corresponded with changes in EMT-associated protein expression, including increased levels of ZO-1 and claudin and decreased β-catenin. CDK2i treatment produced a decrease in Smad3 T179 site non-canonical phosphorylation and inhibited Smad3-Pin1 binding. CDK2i treatment also abrogated TNBC cell migration and invasion, paralleling expression changes in EMT-associated proteins with an increase in claudin and decrease in β-catenin.

Conclusions: Inhibition of the Smad3-Pin1 interaction, through KD of Pin1 expression or CDK2i-mediated blockade of non-canonical Smad3 phosphorylation, reduced TNBC cell EMT-type changes, demonstrated by increased expression of the tight junction proteins ZO-1 and claudin and decreased β-catenin, a key player in the WNT pathway. These findings also correlated to a reduction in TNBC cell migration and invasion. Collectively, these data show that the Smad3-Pin1 interaction, facilitated by CDK-mediated Smad3 phosphorylation, is associated with pro-migratory TGFβ signaling. Inhibition of this interaction, with CDK2 inhibitor treatment, may provide an important therapeutic option for TNBC patients.

Citation Format: Thomas AL, Hamdan R, Hong A, Lind H, Oppat K, Rosenthal E, Thomas AJ, Jeruss JS. Inhibition of Pin1 or CDK-mediated Smad3 phosphorylation reduces triple negative breast cancer cell EMT, migration and invasion [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-07-11.

Abstract P5-04-13: Pin1 negatively impacts Smad3 tumor suppression in triple negative breast cancer cell lines

Introduction: Triple negative breast cancer (TNBC) is an aggressive subtype associated with poor outcomes. Accordingly, there is an urgent need to develop novel and targeted therapeutics for patients with this disease subtype. Cyclins D and E and the corresponding activation of CDK4/2 represent promising therapeutic targets for the treatment of TNBC. CDK4/2 can non-canonically phosphorylate Smad3, a key TGFβ signaling intermediate, to promote the transition from tumor suppressive to oncogenic TGFβ activity in cyclin-overexpressing breast cancers. We identified a Smad3 interaction with Pin1, a cis-trans isomerase also overexpressed in aggressive breast cancers and associated with CDK-mediated Smad3 phosphorylation. Smad3 interaction with Pin1 can influence protein function and fidelity through recruitment of Smurf2 and subsequent proteasomal degradation. Based on these findings, we hypothesized that inhibition of the CDK-mediated Smad3-Pin1 interaction would stabilize Smad3 protein expression and restore tumor-suppressive Smad3 activity.

Methods: Pin1 expression was knocked-down (KD) in MDA-MB-231 TNBC cells by transfecting with Pin1-targeting siRNA (siPin1) or control non-specific siRNA (siNS). KD efficiency was confirmed by immunoblotting. To assay Smad3 transcriptional activity with Pin1 KD, luciferase reporter studies were performed. Also, following Pin1 KD, immunoblotting was used to determine expression of Smad3 and associated protein targets. MTS assays were utilized to determine cellular proliferation after Pin1 KD. Transwell migration assays were used to assay the effect of Pin1 KD or CDK2 inhibitor treatment, which blocked non-canonical Smad3 Thr179 phosphorylation, on TNBC cell migration.

Results: KD of Pin1 expression in TNBC cell lines resulted in an increase in Smad3 transcriptional activity compared to control cells, and correlated with an increase in expression of cdki p15 and a decrease in c-myc, Smad3-target genes and cell cycle regulators. Additionally, Pin1 KD resulted in a significant decrease in TNBC cell proliferation compared to siNS control TNBC cells. Smad3 protein levels increased following Pin1 KD, suggesting Pin1 action may negatively impact Smad3 stability. We also found that KD of Pin1 or treatment with a CDK2 inhibitor, which blocked Smad3 noncanonical Thr179 phosphorylation, resulted in significantly reduced TNBC cell migration.

Conclusions: Inhibiting the Smad3-Pin1 interaction by knock-down of Pin1 expression in TNBC cells restored Smad3 transcriptional activity, which correlated to an increase in expression of the Smad3 associated protein cdki p15, decrease in c-myc, and a decrease in cellular proliferation. Additionally, Pin1 KD enhanced Smad3 protein levels, suggesting a role of Pin1 in mediating Smad3 stability. Inhibiting the Smad3-Pin1 interaction with Pin1 KD or CDK2 inhibitor treatment also reduced TNBC cell migration. Collectively, these data suggest that the Smad3-Pin1 interaction, facilitated by noncanonical CDK-mediated Smad3 phosphorylation, is associated with pro-tumorigenic and pro-migratory TGFβ signaling, and inhibition of this interaction may provide an important therapeutic option for TNBC patients.

Citation Format: Thomas AL, Hamdan R, Hong A, Rosenthal E, Thomas AJ, Jeruss JS. Pin1 negatively impacts Smad3 tumor suppression in triple negative breast cancer cell lines. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-04-13.

Abstract P5-11-01: Impact of CDK mediated Smad3 phosphorylation and Pin1 in triple negative breast cancer cell migration

Introduction: Estrogen receptor (ER), progesterone receptor (PR), and Human Epidermal Growth Factor Receptor 2 (HER2) negative breast cancers, also known as triple negative breast cancers can overexpress cyclins, such as cyclin D and E, which have been linked to cancer progression and metastasis. Cyclin/CDK complexes can phosphorylate and regulate Smads, downstream signaling proteins in the transforming growth factor-beta (TGF-b) superfamily. CDKs phosphorylate Smad3, predominantly in the linker region, resulting in the decreased tumor suppressive role of this protein. The peptidyl-prolyl cis/trans isomerase Pin1 is also overexpressed in breast cancer. Pin1 can bind phosphorylated Smads contributing to TGF-β induced cell migration and invasion. Inhibition of CDK-mediated Smad3 phosphorylation has been shown to restore Smad3 activity and decrease tumor cell migration in vitro. Based on these findings, we hypothesized that inhibition of Pin1 or CDK-mediated Smad3 phosphorylation would result in decreased triple negative breast cancer cell migration.

Methods: Hs578T, MDA-MB-436, and MDA-MB-231 triple negative breast cancer cells (TN) were transfected with either an si control (siCN) or an siPin1 plasmid to knockdown Pin1 protein expression. Transwell migration assays were used to determine the effect of Pin1 knockdown on migration. TN cells were treated with CDK4 or CDK2 inhibitors alone or in combination. The study cells were also stably transduced with lentiviral empty vector, wild-type (WT) Smad3, or a Smad3 mutant (5M) resistant to CDK-mediated phosphorylation. The effect of pharmacologically or genetically inhibiting CDK-mediated Smad3 phosphorylation on Pin1 binding to phosphorylated Smad3 (p-Smad3) or total Smad3 was determined using a co-immunoprecipitation assay (Co-IP).

Results: Transfecting the study cells with siPin1 resulted in decreased cell migration when compared to the siCN transfected cells. Treatment with the CDK4 or CDK2 inhibitors alone or in combination did not affect Pin1 protein levels, but resulted in decreased Pin1 binding to p-Smad3 with the greatest decrease found after treatment with combination therapy. Similarly, transduction of the study cells with the WT or the 5M Smad3 constructs had no effect on Pin1 levels but resulted in decreased Pin1 binding to Smad3. The greatest decrease was observed in the 5M transduced cells.

Concusions: Inhibition of CDK-mediated Smad3 phosphorylation and knock down of Pin1 resulted in decreased migration of TN breast cancer cells. Inhibition of CDK-mediated Smad3 phosphorylation by mutation of the CDK phosphorylation sites or by treatment with CDK4 and CDK2 inhibitors negatively impacted Pin1 binding to Smad3. Together, these findings indicate that CDK-mediated Smad3 phosphorylation enhances Pin1 binding to Smad3 and promotes tumor cell migration in triple negative breast cancer cells.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-11-01.

Abstract P6-04-12: CDK inhibition mediates tumor suppressive Smad3 action and decreased metastatic phenotypes in triple negative breast cancer cells

Introduction: Breast cancer onset and disease progression has been linked to members of the TGFb superfamily and their downstream signaling components, the Smads. Changes in Smad signaling have been associated with the dichotomous role of TGFβ in malignancy, mediating both tumor suppressant and tumor promoting behaviors in breast cancer. Our previous work showed that cyclin/CDK mediated phosphorylation of Smad3 resulted in the inhibition of canonical tumor suppressant Smad3 action. We thus hypothesized that activation of CDKs leads to phosphorylation and inhibition of Smad3, releasing cell cycle arrest and promoting cell proliferation and metastasis. Using triple negative breast cancer cell lines, we examined the impact of specific CDK inhibitors (CDKis) on signaling patterns, metastatic phenotypes, and protein expression profiles.

Methods: Triple negative cell lines Hs578T, MDA-MB-231 and MDA-MB-436 were treated with CDK2i or CDK4i and Smad3 activity was measured using a luciferase assay. Transwell migration and Matrigel invasion assays were used to show the effect of transfection with Smad3 CDK phosphorylation site mutants, resistant to inhibitory CDK phosphorylation, or treatment with CDK2i or CDK4i on the study cells. Immunoblotting was performed to measure protein expression levels of Smad3, pSmad3 T179, and MMP2. A novel live cell array was implemented to quantify changes in activity of 14 cancer-related transcription factors over a period of 3 days. TUNEL and Ki67 staining analysis and a xenograft mouse model were used to determine impact of CDKis, in combination with paclitaxel chemotherapy, on apoptosis and tumor growth respectively.

Results: Treatment of study cells with CDK2i or CDK4i resulted in increased Smad3 activity and decreased migration and invasion in the study cells. Transfection with a 5M Smad3 mutant construct, containing mutations in all 5 CDK phosphorylation sites, resulted in the greatest decrease in cell migration, when compared with cells transfected with both vector control or WT Smad3. CDK2i or CDK4i therapy resulted in decreased Smad3 protein phosphorylation at the T179 site, while total Smad3 levels were unaffected. CDK2i/4i treatment also resulted in decreased MMP2 expression. The array studies revealed decreased activity of EMT transcription factors B-catenin, Snail, Twist, in MDA-MB-231 cells following CDK2i treatment. CDK2i and paclitaxel combination treatment resulted in increased apoptosis and decreased tumor volume and Ki67 staining compared to control treatment.

Conclusions: We have shown for the first time that cyclin/CDK activity, in part, mediates the metastasis-associated role of Smad3 in triple negative breast cancer cells. Importantly, both CDK2i and CDK4i treatment resulted in decreased cell migration/invasion and also corresponded to decreased MMP2 expression. Lastly, the array studies revealed CDK2i mediated effects on key transcription factors associated with the promotion of EMT. Future studies will explore the significance of Smad3 interaction with these EMT factors and will pursue the clinical application of CDK2i for patients with triple negative/cyclin overexpressing breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-04-12.

The effect of aerated rock filter geometry on the rate of nitrogen removal from facultative pond effluents

Rock filters are an established technology for polishing waste stabilization pond effluents. However, they rapidly become anoxic and consequently do not remove ammonium-nitrogen. Horizontal-flow aerated rock filters (HFARF), developed to permit nitrification and hence ammonium-N removal, were compared with a novel vertical-flow aerated rock filter (VFARF). There were no differences in the removals of BOD5, TSS and TKN, but the VFARF consistently produced effluents with lower ammonium-N concentrations (<0.3 mg N/L) than the HFARF (0.8-1.5 mg N/L) and higher nitrate-N concentrations (24-29 mg N/L vs. 17-24 mg N/L).

[Cerebral aneurysm and subarachnoid hemorrhage revealed by a Tako Tsubo syndrome]

Cerebral hemorrhage is usually associated to many cardiac disorders, mimicking acute coronary syndrome. We relate a case of a postmenopausal woman presenting at emergency room for acute coronary syndrome and whose evaluation revealed a subarachnoidal hemorrhage, normal coronary arteries, and a typical Tako Tsubo aspect on echocardiography with apical ballooning and hyperkinesis with basal hypokinesis.

[Heart rate variability alteration in patients on chronic hemodialysis]

BACKGROUND AND AIM

Decrease in heart rate variability (HRV) is a known risk factor for cardiovascular morbidity and mortality. The aim of our study is to evaluate HRV in chronic hemodialysis patients and to determine factors that might decrease or increase it.

METHODS

This is a retrospective study including 51 patients, 23 males and 28 females, with a mean of age of 64.5 years (23-84 years) on chronic hemodialysis for end stage renal disease due to various causes. Twenty-four-hour heart rate monitoring was recorded in all patients to evaluate HRV. HRV of hemodialysis patients was compared to normal patients (control). We also looked for correlation between HRV and a number of clinical and biological factors.

RESULTS

All HRV parameters were decreased in chronic hemodialysis patients compared to normal controls with a significant difference (p<0.0005). HRV decreases with age (p=0.012), and is lower in diabetic patients (p=0.026). Interestingly, we found that chronic hemodialysis patients on beta-blockers had higher HRV with p=0.011.

CONCLUSION

HRV is reduced in chronic hemodialysis patients mainly in old and diabetic patients, but this decrease is less important in those receiving beta-blockers.

[Beneficial effect of sildenafil following surgery for mitral stenosis complicated by pre-capillary pulmonary hypertension: report of two cases]

Pulmonary hypertension is a serious disorder, difficult to treat especially in the severe forms. The treatment consists mainly of calcium channel blockers, anti-coagulation, intravenous epoprostenol, inhaled nitric oxide and recent agents as bosentan and sildenafil. Sildenafil, a phosphodiesterase 5 specific inhibitor, has been largely evaluated in primary pulmonary hypertension, and in some cases of secondary pulmonary hypertension including parenchymal and thromboembolic diseases; it has not yet been evaluated in severe pulmonary hypertension with elevated pre-capillary resistance in operated mitral stenosis. We report the cases of two patients operated from mitral valve replacement for severe mitral stenosis with elevated pre-capillary resistance, where oral sildenafil, introduced empirically immediately after the surgical procedure at the dose of 50 mg/d, permitted a significant decrease in pulmonary pressures and resistances, allowing a rapid withdrawal of nitric oxide and reducing therefore hospitalization time in the intensive care unit. We think that this simple treatment, with or without association to nitric oxide, should be generalized to persistent pulmonary hypertension following cardiac surgery.