Recidiva del hiperparatiroidismo secundario a enfermedad renal crónica en diálisis luego de la paratiroidectomía / Recurrence of secondary hyper¬parathyroidism in dialysis patients after parathyroidectomy

La paratiroidectomía (PTX) es la terapia de elección en el hiperparatiroidismo secundario a enfermedad renal crónica (HPT-ERC) resistente al tratamiento médico. El objetivo del presente estudio fue evaluar el resultado de la PTX a largo plazo y sus factores predictores. Métodos: estudio unicéntrico retrospectivo observacional. Se incluyeron 92 pacientes con HPT-ERC en diálisis, en quienes se realizó la primera PTX en el Hospital Italiano de Buenos Aires entre 2006 y 2015 con seguimiento ≥ 6 meses. Se consideró persistencia del HPTERC con PTH > 300 pg/ml en el semestre posoperatorio, y recidiva con PTH > 500 pg/ml luego. Resultados: edad: 43,6±12,8 años, 50% mujeres, mediana 4,6 años de diálisis, PTH preoperatoria mediana 1639 pg/ml. A 39 se les realizó PTX subtotal (PTXS) y a 53 total con autoimplante (PTXT+AI). Se observó persistencia en 16 pacientes (17,4%). Presentaron recidiva 30 de 76 pacientes con adecuada respuesta inicial (39,5%; IC 95 28,5-50,5). La mediana de tiempo hasta la recidiva fue de 4,7 años (RIC 2,3-7,5). Los pacientes con recidiva presentaron mayor calcemia preoperatoria (mediana 9,9 vs. 9,3 mg/dl, p=0,035; OR ajustado 2,79) y menor elevación de fosfatasa alcalina en el posoperatorio (333 vs. 436 UI/l, p=0,031; OR ajustado 0,99). La recidiva se presentó más frecuentemente luego de la PTXT+AI (48,9%; OR ajustado 4,66), que en la PTXS (25,8%). Conclusiones: el tiempo en diálisis con inadecuado control metabólico constituye el principal factor para la recurrencia del HPT. Se postula que la mayor calcemia preoperatoria está relacionada con un HPT más severo y se asocia a recurrencia. Llamativamente, hallamos menores elevaciones de la fosfatasa alcalina durante el posoperatorio en pacientes con recurrencia. Hipotetizamos que esto pueda asociarse con menor mineralización en el posoperatorio e hiperfosfatemia sostenida, con consecuente estímulo paratiroideo. La menor recurrencia del HPT luego de la PTXS se vincula al sesgo generado en la selección del tipo de cirugía. (AU)

Parathyroidectomy is an effective therapy for refractory secondary hyperparathyroidism (sHPT). Continued dialysis represents risk for recurrent sHPT. The aim of this study was to estimate the proportion of recurrence and determine its predictors. Methods: We conducted a retrospective observational study of 92 adults in chronic dialysis, who underwent their first parathyroidectomy in this center between 2006 and 2015. We considered persistence of sHPT if PTH was > 300 pg/ml during the first postoperative semester, and recurrence if it was > 500 pg/ml afterwards. Results: Age 43.6+-12 y/o, 50% female, 4.6 years on dialysis, median preoperative PTH 1636 pg/ml (IQR 1226-2098). Subtotal parathyroidectomy (sPTX) was performed in 39, Total with autotransplantation (TA-PTX) in 53 patients. Persistence of sHPT occurred in 16 patients; relapse in 30 out of 76 with adequate initially response (39.5%; 95CI 28,5-50,5). Median time to recurrence: 4.7 y. Recurring patients had higher preoperative calcemia (9.9 vs 9.3 mg/dl; adj OR 2.79) and lower postoperative elevation of ALP (333 vs 436 UI/ml; adj OR 0.99). Recurrence presented more frequently in TA-PTX (48.9%; adj OR 4.66) than sPTX (25.8%). Conclusions: Time on dialysis with inadequate metabolic control remains the most important risk factor for sHPT recurrence. Higher preoperative levels of calcemia, related to sHPT severity, are associated with recurrence. Lower elevations of ALP during postoperative period in recurring patients are an interesting finding. We hypothesize that patients with less significant postoperative mineralization may have chronically higher levels of phosphatemia, stimulating parathyroid glands. Fewer recurrence in sPTX is associated to a bias in the procedure selection. (AU)

Improvement of health-related quality of life and adherence to treatment with calcipotriol-betamethasone dipropionate gel in patients with psoriasis vulgaris

Abstract BACKGROUND: Psoriasis is a common, chronic, recurrent, immune-mediated disorder of the skin and joints. It can have a significant negative impact on the physical, emotional and psychosocial wellbeing of affected patients. OBJECTIVES: To measure improvement in health-related QoL (HRQoL) in Greek patients with psoriasis vulgaris after a month of treatment with calcipotriol-betamethasone dipropionate gel; and evaluate adherence to treatment parameters. METHODS: The study included 394 psoriasis vulgaris patients from 16 private dermatological practices in Greece, all treated with calcipotriol-betamethasone dipropionate gel. They were evaluated at the first visit and after 4 weeks. Moreover, they completed the Dermatology Life Quality Index (DLQI), while other data such as disease severity, subjective symptoms and adherence, were collected. RESULTS: At week 4, the DLQI median was reduced by 3.5 points from the baseline (p<0.001; baseline and week 4 median: 4.5 and 1.0 respectively). Pruritus and sleep disorders also improved (p<0.001). Furthermore, 90.1% of the subjects fully adhered to treatment, with a 97.1% mean level of compliance. CONCLUSIONS: The convincing clinical results, with a distinct improvement in HRQoL, plus the high level of adherence due to its advantageous physical properties, make the calcipotriol-betamethasone dipropionate gel formulation an important, effective and well-tolerated topical therapy to treat psoriasis.

Topical calcipotriol as a new therapeutic option for the treatment of clear cell acanthoma

Although uncommonly diagnosed, clear cell acanthoma represents an original source of speculative interest for dermatologists. Due to its clinical variability, it is often only recognized accidentally after histology. Dermoscopy has improved the reliability of clinical diagnosis of typical clear cell acanthoma thanks to the vascular pinpoint pattern and desquamative, peripheral collarette. Generally, therapy of clear cell acanthoma is oriented towards ablative solutions, such as surgery or cryotherapy. We propose a conservative therapy, based on the application of topical calcipotriol, which has produced complete regression after 2 months and no relapse one year after the end of treatment. A dermatoscope monitored all changes of clear cell acanthoma, showing its utility not only in diagnosis but also in therapeutic follow-up. This new therapeutic approach should support an inflammatory etiology of clear cell acanthoma, although further observations are needed to confirm this.

Daivobet(calcipotriol+dipropionato de betametasona) para o tratamento da psoríase / Daivobet (calcipotriol + betamethasone dipropionate) for the treatment of psoriasis

A psoríase é uma das doenças inflamatórias da pele mais frequentes do mundo. Caracteriza-se por lesões eritêmato-descamativas com padrões e distribuição corpórea variáveis, podendo ser classificada fenotipicamente em formas vulgar, gutata, eritrodérmica e pustulosa. A forma mais frequente da psoríase é a psoríase em placas ou vulgar. O número, dimensão e extensão das lesões são variáveis entre os pacientes e conforme a evolução da doença. As lesões surgem sobretudo nos cotovelos, joelhos, região lombar e couro cabeludo, embora possam afetar qualquer área do corpo, cobrindo, nos casos mais graves, extensas áreas do tronco e membros. O Daivobet® é uma combinação de duas substâncias com diferentes mecanismos de ação: hidrato de calcipotriol, um análogo da vitamina D3, com ação anti-proliferativa; e dipropionato de betametasona, um corticosteroide tópico, com potente ação anti-inflamatória. Como existe uma incompatibilidade química entre o calcipotriol e os corticóides de alta potência, não é recomendado que se misture os dois produtos finais. A incompatibilidade se deve ao fato de que o calcipotriol necessita de um alto pH para ter estabilidade e o dipropionato de betametasona só é estável em meio ácido (pH em torno de 3,5). Um veículo inovador permite a combinação dos dois princípios ativos na mesma formulação com garantia da estabilidade dos dois componentes. A evidência atualmente disponível sobre a eficácia do Daivobet® individualmente é limitada, mas como grupo farmacológico (análogo de vitamina D + corticosteróide) fica demonstrado sua eficácia clínica para tratamento tópico da psoríase vulgar, apesar de que esta eficácia é, em algumas circunstâncias, de pouco impacto clínico dependendo do desfecho analisado e do tipo de comparador avaliado. Também temos que ter em consideração a gravidade e o grau de comprometimento do paciente, que como foi observado em outros estudos, os melhores resultados foram obtidos em pacientes com Psoríase Leve, indicação que também é recomendada pelo Consenso Brasileiro de Psoríase. Os membros da CONITEC presentes na reunião ordinária do dia 02/08/2012, por unanimidade, deliberaram por recomendar a não incorporação do medicamento Daivobet® (calcipotriol + dipropionato de betametasona) para o tratamento da psoríase. Foi assinado o Registro de Deliberação nº 15/2012 na 7ª reunião ordinária de 02/08/2012.

Light and electron microscopic studies of the effect of combined topical calcipotriol and PUVA therapy on patients with vitiligo

Vitiligo is an acquired depigmenting disorder that is characterized by loss of melanocytes from the epidermis. A large variety of therapeutic agents are being tried for the treatment of vitiligo, but an optimal treatment is not yet available. This study was conducted to estimate the efficacy of combination of topical calcipotriol and PUVA therapy in patients with vitiligo. Twenty-one patients with vitiligo were enrolled in this study, and were classified into three groups: group 1 [control group], nonlesional [normal] skin biopsies from all included patients in the study; group 2 [pretreated group], biopsies from lesional [vitiligo] skin from all included patients in the study; and group 3 [post-treated group], all included patients in the study, randomly divided into three subgroups: group 3a, included seven patients treated with topical calcipotriol cream [0.005%] twice daily for six months; group 3b, included seven patients treated with PUVA for six months; and group 3c, seven included patients treated with combined topical calcipotriol cream and PUVA twice daily for 6 months. Skin biopsies were taken, fixed, processed, and stained to assess histological changes [H and E], melanin pigment distribution [Masson-Fontana stain], and intercellular adhesion molecule 1 [ICAM-1] expression in the dermis and epidermis [immunohistochemical techniques]. Moreover, for statistical analysis, the mean area percentage of melanin pigment distribution in the epidermis, optical density of ICAM-1 expression in the epidermis and dermis of the immunostained sections, and number of melanosomes [using electron microscope] in the basal and spinous keratinocytes were measured and counted, respectively, in each of the studied groups. Vitiligo biopsies treated with combination of topical calcipotriol and PUVA showed disappearance of mononuclear cell infiltration, highly significant increase in the amount of melanin pigment concentration, highly significant decrease in ICAM-1 expression in the epidermis and dermis, and significant increase in the number of melanosomes when compared with the vitiligo group. Moreover, reappearance of melanocytes and regeneration of keratinocytes ultrastructure were observed. Combined topical calcipotriol and PUVA therapy showed complete repigmentation in vitiligo skin associated with regeneration of keratinocytes and reappearance of melanocytes in a shorter duration when compared with topical calcipotriol or PUVA therapy alone

Low Level Light Could Work on Skin Inflammatory Disease: A Case Report on Refractory Acrodermatitis Continua

Low level laser or light treatment on the various clinical condition is getting considerable attention now. However, there has been no report about the clinical effect of low level polarized polychromatic noncoherent light (LPPL) on the inflammatory skin disease. We experienced a case of acrodermatitis continua in a pregnant woman refractory to any conventional treatment including the most potent topical steroid. She was successfully treated with LPPL. LPPL could be a possible treatment modality producing substantial clinical result in inflammatory skin condition without any side-effect.

Psoriasis ungueal: experiencia con el tratamiento combinado de clobetasol al 8 por ciento en laca ungueal y calcipotriol / Combined clobetasol and calcipotriol treatment for nail psoriasis

La psoriasis ungueal es un problema común en los pacientes psoriáticos, con una incidencia de vida de 90%. A pesar de su alta incidencia y del gran impacto que produce en la calidad de vida, ha sido poco estudiada y el tratamiento óptimo aún no está bien dilucidado. Los corticoides tópicos y los análogos de la vitamina D son las terapias más usadas, pero no existe un esquema estándar para su uso. La combinación de estos agentes se ha estudiado en los últimos años para pacientes con afectación de la matriz y del lecho ungueal, mostrando muy buenos resultados. El caso que presentamos demuestra la sinergia entre estos agentes.

Nail psoriasis is a common problem among psoriatic patients, with a lifetime incidence of 90%. Despite its high incidence and severe impact on the quality of life, it has not been fully studied and the optimal treatment is still unclear. Topical glucocorticosteroids and vitamin D analogues are the most used therapies, but there is no standard therapeutic regimen for their use. The combination of both of these agents has been studied during the last years for the treatment of patients with matrix and bed nail compromise, showing very good results. The case that we present shows the synergy between these agents.

Vitamina D e análogos para o controle do hiperparatireodismo secundário / Vitamin D and analogues in the aontrol of secondary hyperparathyroidism

A vitamina D participa (d)o metabolismo mineral e sua deficiência está associada com doenças extra-ósseas Estudos têm evidenciado hipovitaminose Dna população geral e em renais crônicos. Na progressão da doença renal crônica (DRC), a redução dos níveis de calcitriol, hipocalcemia e hiperfosfatemiasão fatores causais do hiperparatireoidismo secundário (HPTS). Utilizamos o calcitriol para o manejo do HPTS e da hipovitaminose D per se também devemser enfatizadas. Novos análogos da vitamina D, desenvolvidos para substituírem o calcitriol devido à hipercalcemia e hiperfosfatemia associadas ao seuuso, não se mostraram superiores no controle do HPTS. O estado de conhecimento atual sugere a realização de estudos randomizados, controlados ecom amostragem maior para comparar efetividade e segurança entre estes análogos e o calcitriol. Assim, estes estudos poderiam sinalizar para um melhor controle mineral e da doença óssea e resultar em um impacto favorável na morbi-mortalidade na DRC.

Vitamin D has been reported as pivotal for mineral metabolism and bone health, and its deficiency has also been associated with non-skeletal diseases.Many studies have shown high prevalence of vitamin D deficiency in general population as well as in chronic kidney disease (CKD) patients. In CKD progression, low calcitriol levels, hypocalcemia and hyperphosphatemia have all been implicated in the genesis of the secondary hyperparathyroidism (SHPT).In addition to calcitriol supplementation for SHPT management, emphasis should be given to the diagnosis and treatment of vitamin deficiency itself. Newvitamin D analogs were developed in an attempt to overcome the hypercalcemia and hyperphosphatemia that can follow calcitriol treatment but currentknowledge does not allow any conclusion about superiority of new analogs. Large randomized controlled trials studies are needed to compare efficacy and safety of these analogs and calcitriol. These studies could promote a better understanding of mineral metabolism and bone disease control, and result in a favorable impact on morbidity and mortality of CKD patients.

comparison between topical application of calciiotriene, clobetasol and a combination regime of the two drugs in the treatment of Iraqi patients with psoriasis vulgaris

Psoriasis is a chronic relapsing disorder with no Iife long cure, many systemic and topical modalities are available, one of these topical modalities is the vitamin D analogue [calcipotriene] which is widely used recently to treat psoriasis and many other skin problems. Is to compare the safety, the efficacy and the tolerability of tolerability of topical calcipotriene, topical clobetasol and both of them in combination in treating Iraqi patients with psoriasis vulgaris. [The first study in Iraq that uses calcipotriene ointment in treating psoriasis and comparing it with other known topical treatments that were commonly used to treat this problem]. A total of 128 patients with stable plaque psoriasis [72 males and 56 females] with ages between 13 and 68 years and a mean age of 36 years were included in this study, the patients put in four groups: the first one was treated with caicipotriene ointment only, the second was treated with clobetasol ointment only, the third was treated with both drugs in combination and the fourth was treated with Vaseline ointment as placebo. The patients were fully assessed clinically before, during and after the treatment The study showed that the combination therapy was more effective than calcipotriene or clobetasol alone as it significantly reduced the mean perecentage of PASI score within two weeks of treatment [in 55.9%, 42.5% and 31.9% of the patients respectively], the study also showed that the combination therapy had a significantly faster response and a slower relapse rate than that of each drug alone and the effect of calcipotriene appeared to be faster in patients who had no previous treatments. Calcipotriene ointment is a relatively safe, a moderately effective and a well tolerated drug, however, its combination with a potent [very potent] topical corticosteroid will lead to better therapeutic results than the use of each one of them alone

Expression of apoptosis related molecules in response to topical calcipotriol therapy for psoriasis

The histopathologic changes characteristic of psoriasis might be related to suppressed apoptosis. P53 and Bcl-2 proteins play a central role in the regulation of apoptaosis. Skin biopsies were obtained from non-lesional and lesional skin of 10 patients with generalized plaque psoriasis before and after treatment with topical calcipotriol ointment. P53 and Bcl-2 expression was evaluated using immunoperoxidase technique and apoptotic cells by TUNEL method After topical calcipotriol therapy, keratinocytes of psoriatic skin showed significant decrease of P53 [P=0.002] and increase of Bcl-2 [P=0.01] expression. On the other hand lymphocytes showed significant decrease of Bcl-2 [P=0.01]. There were no apoptotic cells before treatment but after calcipotriol therapy, apoptosis was more detected in keratinocytes than in lymphocytes. The results of the present study suggest that one of the actions of calcipotriol in psoriasis might be exerted through induction of apoptosis especially of keratinocytes through a P53 independent- pathway. Meanwhile, suppression of Bcl-2 expression in lymphocytes may promote apoptosis of dermal lymphocytes leading to healing of psoriasis

Daivobet once daily versus twice daily for the treatment of Psoriasis vulgaris

Combination therapy is being used with increasing frequency in the treatment of psoriasis in order to improve the efficacy and reduce side effects. Daivobet is the best example combining the effect of calcipotriol and betamethasone dipropionate. Eighty three patients diagnosed as mild to moderate psoriasis vulgaris were enrolled in the study. They were divided into two groups. The first group of 47 patients were instructed to apply daivobet once daily, the other group of 36 patients applied daivobet twice daily. Psoriasis area and severity index [PASI], was used for evaluation of the response to treatment, after 2, 3, and 4 weeks. The reduction in PASI score at the end of the study was statistically significant for both groups [p-value <0.0001 for both groups]. There was no significant statistical difference regarding efficacy between once daily or twice daily application. We recommend once daily application of topical combination therapy of calcipotriol and betamethazone dipropionate for the treatment of mild to moderate psoriasis which is efficacious with less side effects

Calcipotriol no tratamento da psoríase vulgar / Calcipotriol in the treatment of psoriasis vulgaris

Estudou-se a açäo calcipotriol em 20 doentes portadores de psoríase vulgar estável, examinados no Departamento de Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo. Trata-se de um novo análogo da vitamina D3, que teria açäo na inibiçäo da proliferaçäo celular e diferenciaçäo terminal dos queratinócitos, o que explicaria o efeito terapêutico na psoríase. Aplicado topicamente, à concentraçäo de 50*/g, o calcipotriol mostrou ser eficaz e bem tolerado

Eficácia e segurança do uso de calcipotriol pomada na psoríase vulgar / The efficacy and safety of the use calcipotriol topical application in the psoriasis vulgaris

Os autores estudaram o uso de calcipotriol pomada em 20 pacientes psoriáticos e relatam os resultados obtidos