Scrotal calcinosis in a patient treated with isotretinoin: a rare entity

Scrotal calcinosis is a rare disorder characterized by multiple papules or nodules of calcification in the scrotal skin. The pathogenesis of this disease is poorly understood. The condition presents as several brown to yellowish asymptomatic nodules on the scrotum. Excision followed by scrotal reconstruction is the treatment of choice. It leaves a good cosmetic result with low chances of recurrence. Newer treatments, such as ablative lasers, have been proposed with very good results. We describe the case of a 28-year-old patient with a history of severe acne treated with oral isotretinoin that presented for scrotal nodules. On laboratory examination, hypercalcemia was found with normal phosphorus, parathyroid hormone, and vitamin D hormone levels. Hypercalcemia was linked to his isotretinoin therapy. Serum calcium concentrations normalized after cessation of isotretinoin and hydration. Because the patient refused surgery, a biopsy of the lesion confirmed the diagnosis of scrotal calcinosis. Then the patient was referred to a cosmetic laser center to treat his condition.

Acute Calcific Band Keratopathy as an Adverse Effect of Recombinant Human Nerve Growth Factor (Cenegermin): A Multicenter Case Series

PURPOSE

Cenegermin, (OXERVATE) a recently Food and Drug Administration-approved topical formulation of recombinant human nerve growth factor, has been used for the treatment of neurotrophic keratopathy (NK). Corneal deposits have been previously reported as a potential adverse effect; however, the clinical characteristics, visual significance, and treatment options have not been fully described. The purpose of this article is to better characterize corneal deposits occurring during treatment with cenegermin for neurotrophic keratopathy.

METHODS

This was a retrospective, multicenter consecutive case series.

RESULTS

We identified 5 patients from 3 institutions who developed a white opacity in varying layers of the cornea, consistent with calcium deposition, during treatment with cenegermin. In all cases, the opacity occurred rapidly over the course of a few weeks after initiation of treatment. Histopathologic examination of the cornea from one corneal patient demonstrated extensive calcification of the stroma extending to 90% depth. Before treatment, all patients had stage 2 or 3 NK (Mackie classification). The deposits were visually significant in all patients and did not resolve after cessation of cenegermin. There were no differences in age, sex, etiology of the NK, corneal transplant status, or concurrent medications between the patients who developed a deposit and 15 other patients with stage 2 or 3 NK who did not. One patient was successfully treated with superficial keratectomy with ethylenediaminetetraacetic acid chelation, one patient underwent penetrating keratoplasty, and one patient received a Boston keratoprosthesis.

CONCLUSIONS

We report the rapid onset of a corneal opacity after initiation of treatment with cenegermin in patients with stage 2 or 3 NK, consistent with acute calcific band keratopathy. This visually significant adverse finding has not previously been described. We could not identify any risk factors for development. We recommend close monitoring of patients receiving cenegermin therapy because the opacity may be irreversible and may require keratoplasty for visual rehabilitation.

Ginkgo Biloba Extract EGB761 Alleviates Warfarin-induced Aortic Valve Calcification Through the BMP2/Smad1/5/Runx2 Signaling Pathway

ABSTRACT

Calcific aortic valve disease is a common heart disease that contributes to increased cardiovascular morbidity and mortality. There is a lack of effective pharmaceutical therapy because its mechanisms are not yet fully known. Ginkgo biloba extract (EGB761) is reported to alleviate vascular calcification. However, whether EGB761 protects against aortic valve calcification, a disease whose pathogenesis shares many similarities with vascular calcification, and potential molecular mechanisms remain unknown. In this study, porcine aortic valve interstitial cell (pAVIC) calcification was induced by warfarin with or without the presence of EGB761. Immunostaining was performed to establish and characterize the pAVIC phenotype. Calcium deposition and calcium content were examined by Alizarin Red S staining and an intracellular calcium content assay. Alkaline phosphatase activity was detected by the p-nitrophenyl phosphate method. The expression levels of bone morphogenetic protein-2 (BMP2), Runt-related transcription factor 2 (Runx2), homeobox protein MSX-2, and phosphorylated (p)-Smad1/5 were detected by reverse transcription-quantitative polymerase chain reaction (PCR) and Western blot analysis. Consistent with these in vitro data, we also confirmed the suppression of in vivo calcification by EGB761 in the warfarin-induced C57/Bl6 mice. The results indicated that both pAVICs and aortic valves tissue of mice stimulated with warfarin showed increased calcium deposition and expression of osteogenic markers (alkaline phosphatase, BMP2, homeobox protein MSX-2, and Runx2) and promoted p-Smad1/5 translocation from the cytoplasm to the nucleus. The addition of EGB761 significantly inhibited p-Smad1/5 translocation from the cytoplasm to the nucleus, thus suppressing calcification. In conclusion, EGB761 could ameliorate warfarin-induced aortic valve calcification through the inhibition of the BMP2-medicated Smad1/5/Runx2 signaling pathway.

The intermediate-conductance calcium-activated potassium channel KCa3.1 contributes to alkalinization-induced vascular calcification in vitro

OBJECTIVE

In order to find new strategies for the prevention of vascular calcification in uremic individuals especially treated by dialysis and develop novel therapeutic targets in vascular calcification, we explore the role of KCa3.1 in alkalinization-induced VSMCs calcification in vitro.

METHOD

Rat VSMCs calcification model was established by beta-glycerophosphate (β-GP, 10 mM) induction. The pH of Dulbecco's modified Eagle's medium (DMEM) was adjusted every 24 h with 10 mM HCl or 10 mM NaHCO3 . The mineralization was measured by Alizarin Red staining and O-cresolphthalein complex one method. mRNA and protein expression were detected by RT-PCR and Western blot or immunofluorescence. Ca2+ influx was measured by Elisa.

RESULT

The results indicated that alkalization induced an increase in Ca2+ influx to enhance VSMCs calcification. Furthermore, the increase of calcification was associated with the expression of KCa3.1 via advanced expression of osteoblastic differentiation markers alkaline phosphatase (ALP) and Runt-related transcription factor 2 (Runx2). Blocking KCa3.1 with TRAM-34 or shRNA vector can significantly lowered the effects of calcification in the activity of ALP and Runx2 expression.

CONCLUSION

Together all, our studies suggested that alkalinization can promote vascular calcification by upregulating KCa3.1 channel and enhancing osteogenic/chondrogenic differentiation by upregulating Runx2. The specific inhibitor TRAM-34 and KCa3.1-shRNA ameliorated VSMCs calcification by downregulating KCa3.1.

Extensive Postchemotherapy Calcinosis Cutis in a Non-Hodgkin Lymphoma Patient With Spontaneous Resolution

We report the case of a 30-year-old woman with stage IV, non-Hodgkin lymphoma. Baseline F-FDG PET/CT scan revealed lymphadenopathy with breasts and skeletal involvement. She received 3 cycles of R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone) chemotherapy without significant adverse effects. Biochemical examinations before and after chemotherapies were unremarkable. InterimF-FDG PET/CT showed a partial treatment response. However, there was an appearance of FDG-avid coarse calcification in breasts. Cutaneous and subcutaneous regions of elbows, pelvis, and thighs showed similar calcifications. Posttherapy PET/CT showed a significant resolution of calcinosis cutis. This case presents a postchemotherapy idiopathic calcinosis cutis with rapid spontaneous resolution.

Effect of high-dose vitamin D supplementation on peripheral arterial calcification: secondary analysis of a randomized controlled trial

Although high-dose vitamin D supplementation is common, effects on arterial calcification remain unexplored. Tibial artery calcification was identified and quantified over 3 years in participants randomized to 400, 4000, or 10,000 IU vitamin D₃ daily. High-dose vitamin D supplementation did not affect the development or progression of arterial calcification.

INTRODUCTION

To determine whether vitamin D supplementation has a dose-dependent effect on development and progression of arterial calcification.

METHODS

This was a secondary analysis of the Calgary Vitamin D Study, a 3-year, double-blind, randomized controlled trial conducted at a single-center in Calgary, Canada. Participants were community-dwelling adults aged 55-70 years with serum 25-hydroxyvitamin D 30-125 nmol/L. Participants were randomized 1:1:1 to receive vitamin D₃ 400, 4000, or 10,000 IU/day for 3 years. Tibial artery calcification was identified and quantified (in milligrams of hydroxyapatite, mgHA) using high-resolution peripheral quantitative computed tomography (HR-pQCT) at baseline and 6, 12, 24, and 36 months. Changes in calcification over time and treatment group interaction were evaluated using a constrained linear mixed effects model.

RESULTS

Of 311 randomized participants, 302 (400: 105, 4000: 96, 10,000: 101) were eligible for analysis of arterial calcification (54% male, mean (SD) age 62 (4) years, mean (SD) 25-hydroxyvitamin D 78.9 (19.9) nmol/L). At baseline, 85 (28%) had tibial artery calcification, and mean (95% CI) calcification quantity was 2.8 mgHA (95% CI 1.7-3.9). In these 85 participants, calcification quantity increased linearly by 0.020 mgHA/month (95% CI 0.012-0.029) throughout the study, with no evidence of a treatment-group effect (p = 0.645 for interaction). No participants developed new arterial calcifications during the study.

CONCLUSIONS

In this population of community-dwelling adults who were vitamin D replete at baseline, supplementation with vitamin D 400, 4000, or 10,000 IU/day did not have differential effects on the development or progression of arterial calcification over 3 years.

TRIAL REGISTRATION

clinicaltrials.gov (NCT01900860).

The Ryanodine Receptor Contributes to the Lysophosphatidylcholine-Induced Mineralization in Valvular Interstitial Cells

PURPOSE

Fibrocalcific aortic valve disease (CAVD) is caused by the deposition of calcific nodules in the aortic valve leaflets, resulting in progressive loss of function that ultimately requires surgical intervention. This process is actively mediated by the resident valvular interstitial cells (VICs), which, in response to oxidized lipids, transition from a quiescent to an osteoblast-like state. The purpose of this study was to examine if the ryanodine receptor, an intracellular calcium channel, could be therapeutically targeted to prevent this phenotypic conversion.

METHODS

The expression of the ryanodine receptor in porcine aortic VICs was characterized by qRT-PCR and immunofluorescence. Next, the VICs were exposed to lysophosphatidylcholine, an oxidized lipid commonly found in low-density lipoprotein, while the activity of the ryanodine receptor was modulated with ryanodine. The cultures were analyzed for markers of cellular mineralization, alkaline phosphatase activity, proliferation, and apoptosis.

RESULTS

Porcine aortic VICs predominantly express isoform 3 of the ryanodine receptors, and this protein mediates the cellular response to LPC. Exposure to LPC caused elevated intracellular calcium concentration in VICs, raised levels of alkaline phosphatase activity, and increased calcific nodule formation, but these changes were reversed when the activity of the ryanodine receptor was blocked.

CONCLUSIONS

Our findings suggest blocking the activity of the ryanodine receptor can attenuate the valvular mineralization caused by LPC. We conclude that oxidized lipids, such as LPC, play an important role in the development and progression of CAVD and that the ryanodine receptor is a promising target for pharmacological intervention.

Inhibition of vascular calcification by microRNA-155-5p is accompanied by the inactivation of TGF-β1/Smad2/3 signaling pathway

Vascular calcification (VC) is a vital factor for cardiovascular morbidity and mortality. Accumulating data suggest that microRNA (miR) is implicated in the VC. The main purpose of this study is to study the influence of miR-155-5p overexpression on VC development in vitro and in vivo. Immunofluorescence staining, real-time PCR, alizarin red staining, alkaline phosphatase (ALP) activity assay, western blot, luciferase assay, hematoxylin-eosin (HE), Masson's trichrome staining, and calcium content assay were used in this research. The results showed that miR-155-5p was decreased in the rat vascular smooth muscle cells (rVSMCs) undergoing calcification in vitro. MiR-155-5p overexpression reversed the increase of calcification and ALP activity in calcified cells. Further, overexpression of miR-155-5p inhibited the transforming growth factor-β1 (TGF-β1)/Smad2/3 signaling pathway, as evidenced by decreased protein expression of TGF-β1, pSmad-2 and pSmad-3 in rVSMCs. MiR-155-5p was showed to target Smad2 directly. Moreover, miR-155-5p upregulation reduced vascular thickening, fibrosis and calcium content of aorta abdominalis in CaCl₂-mediated VC model. Collectively, our results suggest that miR-155-5p overexpression may inhibit VC development through suppressing TGF-β1/Smad2/3 signaling pathway in vivo and in vitro, indicating that miR-155-5p may act as a potential therapeutic target for VC-related disease.

A New Nanocomposite Copolymer Based On Functionalised Graphene Oxide for Development of Heart Valves

Polymeric heart valves seem to be an attractive alternative to mechanical and biological prostheses as they are more durable, due to the superior properties of novel polymers, and have the biocompatibility and hemodynamics comparable to tissue substitutes. This study reports a comprehensive assessment of a nanocomposite based on the functionalised graphene oxide and poly(carbonate-urea)urethane with the trade name "Hastalex" in comparison with GORE-TEX, a commercial polymer routinely used for cardiovascular medical devices. Experimental data have proved that GORE-TEX has a 2.5-fold (longitudinal direction) and 3.5-fold (transverse direction) lower ultimate tensile strength in comparison with Hastalex (p < 0.05). The contact angles of Hastalex surfaces (85.2 ± 1.1°) significantly (p < 0.05) are lower than those of GORE-TEX (127.1 ± 6.8°). The highest number of viable cells Ea.hy 926 is on the Hastalex surface exceeding 7.5-fold when compared with the GORE-TEX surface (p < 0.001). The platelet deformation index for GORE-TEX is 2-fold higher than that of Hastalex polymer (p < 0.05). Calcium content is greater for GORE-TEX (8.4 mg/g) in comparison with Hastalex (0.55 mg/g). The results of this study have proven that Hastalex meets the main standards required for manufacturing artificial heart valves and has superior mechanical, hemocompatibility and calcific resistance properties in comparison with GORE-TEX.

Tobacco cigarette smoking exacerbates aortic calcification in an early stage of myocardial infarction in a female mouse model

Despite increased social awareness, marketing restraints, tobacco taxation, and available smoking cessation rehab programs, active and passive smoking remain a worldwide challenging epidemic and a key risk factor for cardiovascular diseases development. Although cardiovascular (CV) protection is more pronounced in women than in men due to estrogenic effects, tobacco cigarette smoking exposure seems to alter this protection by modulating estrogen actions via undefined mechanisms. Premenopausal cigarette smoking women are at higher risk of adverse CV effects than non-smokers. In this study, we investigated the impact of cigarette smoking on early CV injury after myocardial infarction (MI) in non-menopausal female mice. Aortic arch calcification, fibrosis, reactive oxygen species, and gene expression of inflammatory and calcification genes were exaggerated in mice exposed to cigarette smoke (CS). These findings suggest that aortic injury following MI, characterized by vascular smooth muscle cells transdifferentiation, calcification, inflammation, and collagen deposition but not cardiac dysfunction is exacerbated with CS exposure. The novel findings of this study highlight the importance of aortic injury on short and long-term prognosis in CS-exposed MI females. Linking those findings to estrogen alteration is probable and entails investigation.

Intracranial calcifications under vitamin K antagonists or direct oral anticoagulants: Results from the French VIKING study in older adults

OBJECTIVES

The use of vitamin K antagonists (VKA) is associated with the onset of vascular and soft-tissue calcifications. Whether there are more intracranial calcifications under VKA remains unclear. The objective of this study was to determine whether the regular use of VKA in older adults was associated with an increased burden of intracranial calcifications compared with the use of direct oral anticoagulant (DOA).

STUDY DESIGN

Nineteen patients aged 70 years or more using VKA for more than 3 months and 19 controls (matched for age, gender and indication for anticoagulation) using DOA for more than 3 months were consecutively included in this study.

MAIN OUTCOMES MEASURES

The burden of intracranial calcifications was graded by an experienced neuroradiologist from 0 (no burden) to 3 (high burden) according to the quantity, size, intensity and confluence of calcifications on computed tomography scan of the brain. Age, gender, frontal assessment battery (FAB) score, hypertension, dyslipidaemia, carotid artery stenosis, kidney failure and indication for anticoagulation were investigated as potential confounders.

RESULTS

The 19 patients using VKA (median[IQR], 84years[7]; 10females) exhibited a greater burden of falcian calcifications than the 19 controls using DOA (respectively, 2[1] versus 1[2], P = 0.025). Overall, we found that using VKA was directly associated with the global burden of intracranial calcifications (β = 1.54, P = 0.049). No correlation was found with calcifications in sites other than the falx cerebri.

CONCLUSIONS

The use of VKA was associated with a greater burden of intracranial calcifications compared with the use of DOA, specifically in the falx cerebri. This finding may explain part of the neurocognitive morbidity met with VKA.

Warfarin calcifies human aortic valve interstitial cells at high-phosphate conditions via pregnane X receptor

Warfarin, a vitamin K antagonist, is the most common anticoagulant used to prevent thromboembolisms associated with atrial fibrillation or following valvular surgery. Although several studies have revealed that long-term warfarin use accelerates aortic valve calcification and the development of aortic stenosis (AS), the detailed mechanism for this phenomenon remains unclear. Therefore, our aim was twofold: to establish the conditions for warfarin-induced calcification of human aortic valve interstitial cells (HAVICs) using high-inorganic phosphate (Pi) conditions and to investigate the underlying mechanism. We prepared and cultured HAVICs from aortic valves affected by calcific aortic valve stenosis (AS group) and aortic valves affected by aortic regurgitation but without any signs of calcification (non-AS group). Under Pi concentrations of 3.2 mM, warfarin significantly increased the calcification and alkaline phosphatase (ALP) activity of AS but not non-AS group HAVICs. Furthermore, gene expression of bone morphogenetic protein 2 (BMP2), a calcigenic marker, was significantly increased following 7 days of warfarin treatment. Warfarin-induced calcification of AS group HAVICs at 3.2 mM Pi was significantly inhibited by dorsomorphin, a Smad inhibitor, and the pregnane X receptor (PXR) inhibitors, ketoconazole and coumestrol, but was unaffected by SN-50, an NF-κB inhibitor. Warfarin was also able to increase BMP2 gene expression at a physiological Pi concentration (1.0 mM). Furthermore, excess BMP2 (30 ng/mL) facilitated warfarin-induced ALP upregulation and HAVIC calcification, an effect which was significantly reduced in the presence of coumestrol. Together, our results suggest that warfarin accelerates calcification of HAVICs from AS patients via the PXR-BMP2-ALP pathway.

lncRNA-ES3/miR-34c-5p/BMF axis is involved in regulating high-glucose-induced calcification/senescence of VSMCs

Vascular calcification/aging is common in diabetes and is associated with increased morbidity and mortality of patients. MiR-34c-5p, not miR-34c-3p, was suppressed significantly in calcification/senescence of human aorta vascular smooth muscle cells (HA-VSMCs) induced by high glucose, which was proven by the formation of mineralized nodules and staining of senescence associated-β-galactosidase staining (SA β-gal) positive cells. Overexpression of miR-34c-5p alleviated calcification/senescence of HA-VSMCs, whereas inhibition of miR-34c-5p received the opposite results. Bcl-2 modifying factor (BMF) was a functional target of miR-34c-5p and it was involved in the process of calcification/senescence of HA-VSMCs. Besides, lncRNA-ES3 acted as a competing endogenous RNAs (ceRNA) of miR-34c-5p to enhance BMF expression. Further, lncRNA-ES3 inhibited miR-34c-5p expression by direct interaction and its knockdown suppressed the calcification/senescence of HA-VSMCs. Our results showed for the first time that the calcification/senescence of VSMCs was regulated by lncRNA-ES3 /miR-34c-5p/BMF axis.

Investigating potential mediator between statin and coronary artery calcification

Statins are mainstay anti-lipidaemic treatments for preventing cardiovascular diseases but also known to increase coronary artery calcification (CAC). However, underlying relationship between statin and CAC is still unclear. This study explored the mediating role of five statin-related biochemical factors [i.e., low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol, triglyceride, glucose, and high sensitivity C-reactive protein levels]. Seoul Metabolic Syndrome cohort study includes 1370 participants suspected of metabolic syndrome. For causal mediation analysis, the dataset for 2016 including 847 participants with coronary computed tomography without any missing value were analysed using the Mediation package in R software. This study identified a causal mediation mechanism of HDL-cholesterol among the five biochemical factors. It implied that statin treatment increases the HDL-cholesterol level, leading to decreasing the probability of CAC score > 0. Estimated values of interest in HDL-cholesterol mediation were (1) average causal mediation effect, -0.011 with 95% CI [-0.025, -0.003], (2) average direct effect, 0.143 with 95% CI [0.074, 0.219], and total effect, 0.132 with 95% CI [0.063, 0.209]. Its mediation effect was maintained regardless of statin intensity. Sensitivity analysis also provided a robustness of the results under potential existence of a confounder between HDL-cholesterol and CAC. This study suggests a potential causal pathway between statin and CAC (the positive association of statin on CAC) through HDL-cholesterol as an inhibitor.

Worsening of soft tissue dystrophic calcification in an osteoporotic patient treated with teriparatide

Teriparatide, used for treatment of osteoporosis in patients at high risk of fracture risk, sometimes results in mild and transient hypercalcemia. There have been two recent reports of worsening dystrophic calcification in patients with autoimmune disorders following teriparatide treatment. We report a patient with severe osteoporosis and without a pre-existing autoimmune disorder, who developed symptomatic worsening of dystrophic calcification 4 months after teriparatide was initiated. Symptoms resolved within 1 week of teriparatide cessation.

Vitamin K2 regression aortic calcification induced by warfarin via Gas6/Axl survival pathway in rats

The aim of this study was to investigate the effect of vitamin K2 on aortic calcification induced by warfarin via Gas6/Axl survival pathway in rats. A calcification model was established by administering 3mg/g warfarin to rats. Rats were divided into 9 groups: control group (0W, 4W, 6W and 12W groups), 4W calcification group, 6W calcification group, 12W calcification group, 6W calcification+6W normal group and 6W calcification+6W vitamin K2 group. Alizarin red S staining measured aortic calcium depositions; alkaline phosphatase activity in serum was measured by a kit; apoptosis was evaluated by TUNEL assay; protein expression levels of Gas6, Axl, phosphorylated Akt (p-Akt), and Bcl-2 were determined by western blotting. The calcium content, calcium depositions, ALP activity and apoptosis were significantly higher in the calcification groups than control group. Gas6, Axl, p-Akt and Bcl-2 expression was lower in the calcification group than control group. 100μg/g vitamin K2 treatment decreased calcium depositions, ALP activity and apoptosis significantly, but increased Gas6, Axl, p-Akt and Bcl-2 expression. 100μg/g vitamin K2 reversed 44% calcification. Pearson correlation analysis showed a positive correlation between formation calcification and apoptosis (R(2)=0.8853, P<0.0001). In conclusion, we established a warfarin-induced calcification model and showed vitamin K2 can inhibit warfarin-induced aortic calcification and apoptosis. The regression of aortic calcification by vitamin K2 involved the Gas6/Axl axis. This data may provide a theoretical basis for future clinical treatments for aortic calcification.

Clinical Search for Undiagnosed Mesenteric Phlebosclerosis at Outpatient Departments Specializing in Herbal (Kampo) Medicine

OBJECTIVE

Mesenteric phlebosclerosis (MP) is a disease characterized by calcification of the mesenteric vein, which causes chronic mesenteric ischemia. Recently, the long-term intake of gardenia fruit ('Sanshishi' in Japanese) has been attracting attention as a possible cause. Usually, only advanced, severe MP cases get reported. However, we suspected that some latent cases of this disease may exist. We performed this study in order to determine the prediagnostic cases at our outpatient departments of herbal (Kampo) medicine, with particular attention paid to the initial changes, such as any slight color change of the colon, as shown in colonoscopy.

METHODS

We recommend colonoscopy and computed tomography (CT) scans for patients with a long-term history of taking herbal medicines containing gardenia fruit. Clinical examinations were performed upon receiving patients' consent from December 2013 to November 2014.

RESULTS

Of the 103 patients who took gardenia fruit long-term, 29 agreed to be checked for MP. 14 patients underwent colonoscopy. Four patients were confirmed to have MP due to the presence of fibrotic deposition of the colonic membrane on histological inspection. Twenty-one patients underwent abdominal CT screening. Characteristic calcification of the mesenteric vein was observed on CT scans in 2 patients. All 4 MP patients took Kampo formulas containing gardenia fruit for more than 6.8 years. The other patients did not develop MP, despite long-term gardenia fruit intake.

CONCLUSION

We detected the latent and undiagnosed MP cases. All diagnoses were made while paying careful attention to any slight changes in colonoscopy and CT scans.

Mitral Valve Stenosis Progression Due to Severe Calcification on Glutaraldehyde-Treated Autologous Pericardium: Word of Caution for an Attractive Repair Technique

A 42-year-old woman presented with a 6-month history of palpitations and progressive dyspnea on exertion. She had undergone aortic and mitral valve repair using glutaraldehyde-treated autologous pericardium for active infective endocarditis 5 years prior. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification of the glutaraldehyde-treated pericardial patch on the anterior mitral leaflet was observed. Double valve replacement was performed with pulmonary vein isolation. Pathologic examination showed calcification of the glutaraldehyde-treated autologous pericardium. The patient was discharged on postoperative day 11 with oral anticoagulant therapy.

Corneal calcification and phosphates: do you need to prescribe phosphate free?

PURPOSE

Both superficial band keratopathy and deeper calcareous calcification have been linked to the presence of phosphate excipients in topical ophthalmic medicines. (1-3) The European Medicines Agency (EMA) has concluded that patients with ocular surface disease are at greatest risk. This potential side effect should be highlighted to both prescribers and patients. (4) We aimed to review the excipients of commonly prescribed ophthalmic medicines to prepare a list of phosphate-containing drugs and also to investigate where to find this information.

METHODS

We reviewed 78 commonly used ophthalmic drops and ointments for the information about their excipients. We reviewed the information written on drug boxes, bottles, patient leaflets, and in the electronic Medicines Compendium (EMC), which contains up-to-date details of all medicines licensed for use in the United Kingdom. The British National Formulary (BNF) was also reviewed.

RESULTS

We found 22 phosphate-containing, 13 unbuffered, and 43 ophthalmic drugs containing buffers other than phosphate based. Most displayed the list of their excipients on their boxes and in patient leaflets. This information was also available on the EMC website but not in the BNF. Despite the EMA recommendation, none of the phosphate-containing medicines mentions corneal calcification as a potential side effect.

CONCLUSIONS

We present a reference list of phosphate-based ophthalmic drugs to be used with caution for patients with a compromised ocular surface. We found the EMC to be a reliable and easily accessible source of information about drug components. This information will also be included in the new editions of the BNF.

[Calcinosis cutis treatment with extracorporeal shockwave therapy]

Calcinosis cutis is a rare disease entity characterized by deposits of calcium in the skin and subcutaneous tissue causing hard-to-heal ulcers. This is a case report on a patient with femoral ulcers in connection with densely mineralized skin caused by ketobemidon injections. Next to surgical excision of calcified tissue the patient received extracorporeal shockwave therapy (ESWT). On the basis of excellent healing, partial skin transplant was feasible. We advocate for randomized trials on ESWT as an adjunctive therapy for complex non-healing wounds.

Prevalence of skeletal fluorosis in fisherman from Kutch coast, Gujarat, India

BACKGROUND

In health terms, consuming fluoride is well recognised to be a double-edged sword. Consumption of optimal amounts is beneficial to health, however an excess constitutes a health hazard.

OBJECTIVES

To assess the prevalence of skeletal fluorosis in fishermen from the Kutch coast, Gujarat, India.

MATERIALS AND METHOD

A descriptive cross-sectional survey was conducted on 653 fishermen from the Kutch District, Gujarat, India, from October 2014 to December 2014. Clinical skeletal fluorosis was assessed using three diagnostic tests. Drinking water fluoride concentrations in different regions of the study area were determined. General information regarding age, gender and adverse habits were also collected. The Chi square test was used for comparisons and the confidence level and critical p-value were set at 95% and 5% respectively.

RESULTS

Fluoride concentrations in water from the study area ranged between 3.4-6.9 ppm. The prevalence of skeletal fluorosis was 30.3%, out of which, the majority of the subjects had mild skeletal fluorosis (18.4%). This condition was found to be significantly associated with age and gender along with tobacco and alcohol consumption; depending on the habit's duration.

CONCLUSION

Being a public health problem in the fishermen community, skeletal fluorosis requires a-priori attention. Measures for preventing this disease should be undertaken on a communitywide basis.

Generation of Simulated Calcific Lesions in Valve Leaflets for Flow Studies

BACKGROUND AND AIM OF THE STUDY

Calcific aortic valve disease (CAVD) is the most common valvular disorder. While fluid stresses are presumed to play a role in disease progression, the valvular hemodynamic changes experienced over the course of CAVD remain largely unknown. The study aim was to develop a laboratory protocol for the fabrication of tissue valve models mimicking mild and moderate calcific stenosis, for future use in flow studies.

METHODS

Different hydroxyapatite (HA)-agarose mixtures were injected into porcine valve leaflets. Micro-computed tomography (micro-CT) was used to quantify HA deposition volume, area fraction and regional distribution, while von Kossa staining was performed to assess tissue mineralization. Particle image velocimetry measurements were carried out in intact and injected valves subjected to in vivo-like hemodynamics to characterize the degree of valvular stenosis in terms of geometric orifice area (GOA) and peak systolic velocity.

RESULTS

The 5% HA-1% agarose solution (solution 1) and the 5% HA-0.5% agarose solution (solution 2) maximized the HA deposition volume. Leaflet injections with solution 1 resulted in a significant 1.9-fold increase in HA area fraction relative to solution 2 injections. While solution 1 injections generated multiple sites of high HA concentration, solution 2 injections produced smaller, discrete spots. Injections of both solution 1 and solution 2 into whole valves generated significant 47% and 32% reductions, respectively, in GOA and 1.8-fold and 1.5-fold increases, respectively, in peak systolic velocity, relative to untreated valves.

CONCLUSION

Tissue valve models were generated that recapitulated the structure and hemodynamics of mild and moderate valvular calcification. Those models may be used for future investigations of the native valvular hemodynamic alterations that occur during CAVD.

Quetiapine responsive catatonia in an autistic patient with comorbid bipolar disorder and idiopathic basal ganglia calcification

BACKGROUND

Bipolar disorder (BD) has been linked with the manifestation of catatonia in subjects with autism spectrum disorders (ASD). Idiopathic basal ganglia calcification (IBGC) is characterized by movement disorders and various neuropsychiatric disturbances including mood disorder.

CASE

We present a patient with ASD and IBGC who developed catatonia presenting with prominent dystonic feature caused by comorbid BD, which was treated effectively with quetiapine.

CONCLUSION

In addition to considering the possibility of neurodegenerative disease, careful psychiatric interventions are important to avoid overlooking treatable catatonia associated with BD in cases of ASD presenting with both prominent dystonic features and apparent fluctuation of the mood state.

The pathophysiology of smoking during pregnancy: a systems biology approach

This article focuses on a systems biology approach to studying the pathophysiology of cigarette smoking during pregnancy. Particular emphasis is given to the damaging role of oxidative stress. Cigarette smoking exerts multiple adverse affects but abundant evidence, mostly in adults, suggests that oxidative stress and free radical damage is a major pathophysiological factor. Smoking during pregnancy is known to contribute to numerous poor birth outcomes, such as low birth weight, preterm birth as well as life-long health and developmental problems. It is clinically important to know the separate contributions that cigarette derived-nicotine and smoking-induced free oxidative stress make to these poor outcomes. Surprisingly, the extent to which smoking dependent oxidative stress contributes to these poor outcomes is not well studied but the application of redox proteomics should be useful. Considerable biochemical evidence suggests that antioxidants, such as tocopherols and ascorbate, could be useful in minimizing oxidative stress induced pathology to the developing fetus in those women who, despite medical advice, continue to smoke. Nevertheless, this suggestion has yet to be tested in well-designed clinical studies.

Transforming growth factor β1 is not a reliable biomarker for valvular fibrosis but could be a potential serum marker for invasiveness of prolactinomas (pilot study)

BACKGROUND

Transforming growth factor β1 (TGFβ1) signaling pathway is crucial for both human fibrogenesis and tumorigenesis.

OBJECTIVE

This study aimed to investigate the usefulness of TGFβ1 and matrix metalloproteinase 2 (MMP2) as potential circulating markers for fibrotic valvular heart disease (FVHD) and invasiveness as well as of Fetuin A as a marker for calcification in patients with prolactinomas.

DESIGN

The study population consisted of 147 subjects divided into four groups: 30 dopamine agonist (DA)-treated prolactinoma patients with proven FVHD and three control groups with normal echocardiograms: 43 DA-treated patients, 26 naïve patients, and 48 healthy subjects.

RESULTS

We observed significantly higher serum TGFβ1 levels in all three patient groups than in the healthy subjects (21.4 ± 8.86 vs 19.1 ± 9.03 vs 20.7±11.5 vs 15.8 ± 7.2 ng/ml; P=0.032). Moreover, TGFβ1 levels were significantly higher in patients with macroprolactinomas and invasive prolactinomas than in those with microprolactinomas and noninvasive tumors respectively. In addition, a strong positive linear relationship between TGFβ1 levels and invasiveness score (ρ=0.924; P<0.001) and a moderate correlation between TGFβ1 levels and tumor volume (r=0.546; P<0.002) were observed in patients with invasive prolactinomas. By contrast, prolactin (PRL) levels exhibited a better correlation with tumor volume (r=0.721; P<0.001) than with invasiveness score (ρ=0.436; P<0.020). No significant difference was observed in Fetuin A levels between patients with FVHD and healthy controls. Results concerning MMP2 were unclear.

CONCLUSIONS

TGFβ1, MMP2, and Fetuin A are not reliable biomarkers for valvular fibrosis and calcification in DA-treated patients with prolactinomas, but TGFβ1 may represent a useful serum marker for tumor invasiveness. The simultaneous determination of TGFβ1 and PRL levels could improve the noninvasive assessment of prolactinoma behavior.

Lanthanum prevents high phosphate-induced vascular calcification by preserving vascular smooth muscle lineage markers

Vascular calcification (VC) represents a major cardiovascular risk factor in chronic kidney disease patients. High phosphate (Pi) levels are strongly associated with VC in this population. Therefore, Pi binders are commonly used to control high Pi levels. The aim of this work was to study the mechanism of action of lanthanum chloride (LaCl3) on the progression of Pi-induced VC through its direct effect on vascular smooth muscle cells (VSMCs) in vitro. High Pi induced VSCM Ca deposition. We evaluated the action of LaCl3, compared to gadolinium chloride (GdCl3), and found different effects on the modulation of VSMC lineage markers, such as α-actin and SM22α. In fact, only LaCl3 preserved the expression of both VSMC lineage markers compared to high Pi-treated cells. Interestingly, both LaCl3 and GdCl3 reduced the high Pi-induced elevations of bone morphogenic protein 2 mRNA expression, with no reduction of the high core binding factor-alpha 1 mRNA levels observed in calcified VSMCs. Furthermore, we also found that only LaCl3 completely prevented the matrix GLA protein mRNA levels and osteonectin protein expression elevations induced by high Pi compared to GdCl3. Finally, LaCl3, in contrast to GdCl3, prevented the high Pi-induced downregulation of Axl, a membrane tyrosine kinase receptor involved in apoptosis. Thus, our results suggest that LaCl3 prevents VC by preserving VSMC lineage markers and by decreasing high Pi-induced osteoblastic differentiation.

Vitamin K-antagonists accelerate atherosclerotic calcification and induce a vulnerable plaque phenotype

BACKGROUND

Vitamin K-antagonists (VKA) are treatment of choice and standard care for patients with venous thrombosis and thromboembolic risk. In experimental animal models as well as humans, VKA have been shown to promote medial elastocalcinosis. As vascular calcification is considered an independent risk factor for plaque instability, we here investigated the effect of VKA on coronary calcification in patients and on calcification of atherosclerotic plaques in the ApoE(-/-) model of atherosclerosis.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 266 patients (133 VKA users and 133 gender and Framingham Risk Score matched non-VKA users) underwent 64-slice MDCT to assess the degree of coronary artery disease (CAD). VKA-users developed significantly more calcified coronary plaques as compared to non-VKA users. ApoE(-/-) mice (10 weeks) received a Western type diet (WTD) for 12 weeks, after which mice were fed a WTD supplemented with vitamin K(1) (VK(1), 1.5 mg/g) or vitamin K(1) and warfarin (VK(1)&W; 1.5 mg/g & 3.0 mg/g) for 1 or 4 weeks, after which mice were sacrificed. Warfarin significantly increased frequency and extent of vascular calcification. Also, plaque calcification comprised microcalcification of the intimal layer. Furthermore, warfarin treatment decreased plaque expression of calcification regulatory protein carboxylated matrix Gla-protein, increased apoptosis and, surprisingly outward plaque remodeling, without affecting overall plaque burden.

CONCLUSIONS/SIGNIFICANCE

VKA use is associated with coronary artery plaque calcification in patients with suspected CAD and causes changes in plaque morphology with features of plaque vulnerability in ApoE(-/-) mice. Our findings underscore the need for alternative anticoagulants that do not interfere with the vitamin K cycle.

[Calcified]

A 73-year-old woman was referred due to an acute and progressive worsening of a previously mildly impaired kidney function of unknown origin. The kidney biopsy showed a phosphate nephropathy. We identified Colophos®, a phosphate-containing purgative as the causing agent, which the patient had received for bowel cleansing for a colonoscopy one day before the detection of the acute kidney failure. During the following months the kidney function initially declined further and then improved. Most cases of phosphate nephropathy are associated with the ingestion of phosphate-containing purgatives. Persons at risk are women, elderly persons, patients with impaired kidney function, hypertension, and dehydration. The consequence is sometimes an irreversible tubulointerstitial injury that can lead to end-stage renal disease in a minority of the cases.

An unusual adverse effect of nadroparin injections: Calcinosis cutis

In 1988, Tumiati et al described the first case of calcinosis cutis related to a calcium-containing heparin. Since then, only 18 cases have been reported in the literature; they usually have an altered calcium-phosphate product, an elevated parathyroid hormone (PTH), or both. We report a 33-year-old patient who developed calcinosis cutis at sites of nadroparin injections without any disturbance of calcium-phosphate product, PTH, or vitamin D. The pathogenesis of calcinosis cutis secondary to nadroparin injections remains controversial; Proposed causes included metastatic, dystrophic, iatrogenic, or multifactorial etiologies. This is the first case of multiple nodules of calcinosis cutis without alterations of calcium-phosphate product, PTH, or vitamin D, which supports an iatrogenic mechanism. We also suggest that calcinosis cutis could be more frequent than we thought and is probably an underdiagnosed entity.