Regression of calcinosis cutis after inkless tattoo in a patient with dermatomyositis: therapeutic potential of microneedling.

Calcinosis cutis is defined as abnormal deposition of calcium salts in the skin and subcutaneous tissues. Dystrophic calcification, the most common form of calcinosis cutis, is associated with autoimmune connective tissue diseases. This condition is associated with severe pain and can affect the patient's quality of life and lead to long-term disability. Treatment is often challenging, and there is a very limited evidence base for potential treatments of calcinosis cutis associated with systemic sclerosis and dermatomyositis. Inkless tattoo is very similar to microneedling, a minimally invasive procedure stimulating the wound-healing cascade contributing to elastin and collagen formation as well as neovascularization. This technique has not been reported as a potential therapeutic option for calcinosis cutis. Here, we present a patient with calcinosis cutis in the setting of dermatomyositis that responded dramatically to inkless tattoo application. Our results support the need for future studies of microneedling in patients with this disorder.

Nutritional Supplements and Skeletal Health.

PURPOSE OF REVIEW: Nutrition influences skeletal health throughout the lifespan, from the impact of maternal intakes during development, through the development of peak bone mass, to the rate of bone loss during aging. However, there are limited data available on the effects of nutritional supplements on bone density, let alone fracture risk. This review will assess the current literature, focusing on human studies, and emphasizing nutrients where bone density or fracture data are available. RECENT FINDINGS: Calcium and vitamin D supplements, in combination, reduce fracture risk, particularly in populations with low intakes. Extensive recent analyses have supported the safety of these interventions at recommended intakes. There is growing evidence that specific isoflavones may improve bone density although fracture data are lacking. Multiple other nutrient supplements may benefit skeletal health, but data are limited. The effect size of nutrient interventions are relatively small, requiring large sample sizes for trials with bone outcomes, may be difficult to blind, and the impact of supplementation may depend on baseline intake. However, nutrition is the only intervention that can be implemented life long and on a population wide basis. Further investigation is needed into the potential benefits of nutritional supplements to determine in which settings supplements may add benefit in addition to dietary intakes.

FRACTURE LIAISON SERVICES: MULTIDISCIPLINARY APPROACHES TO SECONDARY FRACTURE PREVENTION.

OBJECTIVE: A well-recognized gap exists between evidence-based recommendations for post-fracture care and actual clinical practice, demonstrated by the high percentage of fragility fracture patients who are neither diagnosed nor treated for osteoporosis. Our purpose is to review fracture liaison service (FLS) models and to evaluate national and international experiences in secondary fracture prevention. METHODS: We performed a systematic search of publication databases (MEDLINE, SCOPUS) and included randomized controlled trials, meta-analyses, and review articles using the following keywords: Fracture liaison services, Secondary prevention of fracture, Post-fracture healthcare gap, and fragility fractures. References were included from 2001-2015. We subsequently performed reference searches of retrieved articles and available literature was reviewed. RESULTS: The efficacy of secondary fracture prevention programs correlates strongly with their intensity. Type A FLS Models are most successful in initiating diagnostic and treatment plans for fragility fracture patients. Adoption of FLS programs improves care by lowering mortality and refracture rates while also lowering healthcare costs. The quality of evidence supporting associations between FLS programs and improved outcomes was moderately strong due to the availability of longitudinal data from nationalized health systems. CONCLUSION: As our population ages and challenges to the healthcare system loom ever larger, it is imperative that we fund and champion fracture liaison services. The fracture liaison service has recently emerged as a novel clinical approach that uses coordinated, multidisciplinary care to improve post-fracture outcomes and reduce recurrent fractures. These programs are simple, targeted, high-yield and have the potential to protect our most vulnerable patients. ABBREVIATIONS: DXA = dual-energy x-ray absorptiometry FLS = fracture liaison service NCQA = National Committee of Quality Assurance NHS = National Health Service PCP = primary care physician PQRS = Physician Quality Reporting System QCDR = Qualified Clinical Data Registry.

A Randomized Controlled Trial of Exercise to Prevent Bone Loss in Premenopausal Women with Breast Cancer.

Background/Introduction/Objective: Premenopausal women treated for breast cancer are at high risk for bone loss. This trial examined the effects of a 1-year combined aerobic and resistance exercise program on bone mineral density (BMD) in women treated for premenopausal breast cancer. MATERIALS AND METHODS: Premenopausal women (n = 206) age ≤ 55 years at cancer diagnosis who were within two years of receiving adjuvant chemotherapy were randomized to a 12-month exercise program or a control group. BMD was measured by dual-energy X-ray absorptiometry at baseline and after 1 year; blood was drawn for skeletal markers. Change from baseline to end of study was compared within and between treatment groups using paired and unpaired t-tests. RESULTS: Lumbar spine BMD declined in both treatment groups with no significant difference between treatment groups (-0.008 ± 0.003 g/cm2 exercise vs. -0.014 ± 0.003 g/cm2 control, p = 0.24). However, among the women who did not lose lean mass during the study (n = 100, 54 control, 46 exercise), the exercise intervention prevented lumbar spine bone loss (0.001 ± 0.005 g/cm2 treatment group vs. -0.014 ± 0.005 g/cm2 control group, p = 0.03). Bone turnover markers decreased significantly in both groups with no differences between groups. CONCLUSIONS: Among women who maintained lean mass, our exercise intervention prevented bone loss; however, our intervention did not prevent bone loss among women who lost muscle mass. Additional investigation into exercise regimens that can prevent both bone and muscle loss may help prevent long-term consequences of premenopausal breast cancer treatment.

Stage-Based Management of Type 2 Diabetes Mellitus with Heart Failure.

Type 2 diabetes negatively impacts heart failure outcomes. Insulin resistance, central adiposity, dyslipidemia, and altered cellular substrate metabolism each have a mechanistic role. Management strategies focused solely on glycemic control have had limited success. However, three new classes of drugs, each with several options, offer the promise of improved diabetes management in heart failure. Unlike earlier classes, these medications have had favorable cardiovascular outcomes. In this review, we present a therapeutic guide for metabolic treatment based on the stages of heart failure.

The Parathyroid Gland and Heart Disease.

The parathyroid glands are critical to maintaining calcium homeostasis through actions of parathyroid hormone (PTH). Recent clinical and molecular research has shown that direct and indirect actions of PTH also affect the heart and vasculature through downstream actions of G protein-coupled receptors in the myocardium and endothelial cells. Patients with disorders of the parathyroid gland have higher incidences of hypertension, arrhythmias, left ventricular hypertrophy, heart failure, and calcific disease which translate into increased cardiac morbidity and mortality. Importantly, clinical research also suggests that early treatment of parathyroid disorders through medical or surgical management may reverse cardiovascular remodeling and mitigate cardiac risk factors.

FSH Levels Predict Bone Loss in Premenopausal Women Treated for Breast Cancer More Than One Year After Treatment.

CONTEXT: Biomarkers to predict bone loss in premenopausal women after breast cancer treatment have not been examined. OBJECTIVE: To determine whether baseline FSH predicts subsequent bone loss. DESIGN: Secondary data analysis of the Exercise for Bone Health: Young Breast Cancer Survivors study, in which women were randomized to a 12-month exercise program or monthly health newsletter. SETTING: Community dwelling women. PARTICIPANTS: A total of 206 women age less than or equal to 55 years at breast cancer diagnosis who had received adjuvant chemotherapy and were at least 1 year after diagnosis. INTERVENTION: Serum collected at baseline (an average of 302 ± 148 d after completing chemotherapy) was analyzed for FSH. MAIN OUTCOME MEASURE: Change in bone mineral density. RESULTS: In linear regression models, baseline FSH levels predicted bone loss over the ensuing 12 months at the lumbar spine and femoral neck including after adjustment for age, ethnicity, treatment group (exercise vs control), baseline bone density, and high-sensitivity C-reactive protein (P < .001). In multiply adjusted models, the 12-month rate of change in bone density was +0.007% in the lowest tertile of FSH (FSH = 9 ± 7 IU/L, mean ± SD), -0.96% in the middle tertile (mean FSH = 41 ± 11 IU/L), and -2.2% in the highest tertile (mean FSH = 86 ± 19 IU/L), P for trend <.001. CONCLUSIONS: Among premenopausal women with breast cancer treated with chemotherapy, baseline FSH levels are strongly associated with subsequent bone loss. Further studies are needed to establish the optimal timing of FSH measurement in relation to breast cancer treatment and to investigate potential strategies to prevent bone loss.