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(searched for: Vitamin D Levels in Chronic Diseases in Primary Care)
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Der Internist, Volume 58, pp 1029-1036; doi:10.1007/s00108-017-0311-3

The publisher has not yet granted permission to display this abstract.
Sciprofile linkMelvin H. Seid, Angelia D. Butcher, Ashwin Chatwani
Published: 13 April 2017
Anemia, Volume 2017, pp 9642027-9; doi:10.1155/2017/9642027

Abstract:
Objective. To evaluate safety and efficacy of intravenous ferric carboxymaltose (FCM) versus standard medical care (SMC) for iron-deficiency anemia (IDA) in postpartum women and women with heavy menstrual bleeding. Study Design. This open-label, multicenter study randomized women with IDA (hemoglobin ≤ 11.0 g/dL) to single doses of FCM (15 mg/kg [maximum 1000 mg]) or SMC (this treatment was determined by the investigator and there may have been no treatment). Safety data (primary outcome) were collected for 30 days. Results. Of 2045 subjects enrolled (FCM: n = 1023; SMC: n = 1022), 996 received FCM and 1022 received SMC. At least 1 serious adverse event (AE) was reported by 0.6% and 2.2% of subjects in the FCM and SMC groups, respectively; none were considered treatment related. The difference in serious AEs was primarily due to higher rates of uterine leiomyoma, uterine hemorrhage, and menorrhagia in SMC subjects with heavy menstrual bleeding. Common AEs were generally predictable, with higher rates of infusion site reactions in FCM subjects and gastrointestinal AEs in SMC subjects. Mean hemoglobin increases were greater in the FCM group than the SMC group. Conclusion. FCM was well tolerated and effectively increased mean hemoglobin levels in postpartum women or women with heavy menstrual bleeding and IDA. This trial is registered with ClinicalTrials.gov, NCT00548860.
Luciene P. Magalhães, Luciene M. Dos Reis, Fabiana G. Graciolli, Benedito J. Pereira, Rodrigo B. De Oliveira, Altay A. L. De Souza, Rosa M. Moyses, Rosilene M. Elias, Sciprofile linkVanda Jorgetti
Published: 3 January 2017
PLOS ONE, Volume 12; doi:10.1371/journal.pone.0167895

Abstract:
Chronic kidney disease (CKD) affects 10–15% of adult population worldwide. Incident patients on hemodialysis, mainly those on urgent-start dialysis at the emergency room, have a high mortality risk, which may reflect the absence of nephrology care. A lack of data exists regarding the influence of baseline factors on the mortality of these patients. The aim of this study was to evaluate the clinical and laboratory characteristics of this population and identify risk factors that contribute to their mortality. We studied 424 patients who were admitted to our service between 01/2006 and 12/2012 and were followed for 1 year. We analyzed vascular access, risk factors linked to cardiovascular disease (CVD) and mineral and bone disease associated with CKD (CKD-MBD), and clinical events that occurred during the follow-up period. Factors that influenced patient survival were evaluated by Cox regression analysis. The patient mean age was 50 ± 18 years, and 58.7% of them were male. Hypertension was the main cause of primary CKD (31.8%). Major risk factors were smoking (19.6%), dyslipidemia (48.8%), and CVD (41%). Upon admission, most patients had no vascular access for hemodialysis (89.4%). Biochemical results showed that most patients were anemic with high C-reactive protein levels, hypocalcemia, hyperphosphatemia, elevated parathyroid hormone and decreased 25-hydroxy vitamin D. At the end of one year, 60 patients died (14.1%). These patients were significantly older, had a lower percentage of arteriovenous fistula in one year, and low levels of 25-hydroxy vitamin D. The combined evaluation of clinical and biochemical parameters and risk factors revealed that the mortality in urgent-start dialysis is associated with older age and low levels of vitamin D deficiency. A lack of a permanent hemodialysis access after one year was also a risk factor for mortality in this population.
S. Papapoulos
Published: 1 June 2016
by BMJ
Annals of the Rheumatic Diseases, Volume 75, pp 41.3-41; doi:10.1136/annrheumdis-2016-eular.6293

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Journal of the American Association of Nurse Practitioners, Volume 27, pp 415-419; doi:10.1002/2327-6924.12217

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S. Papapoulos
Published: 9 June 2015
by BMJ
Annals of the Rheumatic Diseases, Volume 74, pp 4.2-4; doi:10.1136/annrheumdis-2015-eular.6836

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Critical Care, Volume 19; doi:10.1186/s13054-015-0812-1

Abstract:
Decreased production of cathelicidin antimicrobial protein-18 (hCAP18) has been proposed to be a key mechanism linking decreased 25-hydroxyvitamin D (25D) levels with adverse outcomes among critically ill patients. However, few studies in humans have directly assessed plasma hCAP18 levels, and no study has evaluated the association between hCAP18 levels and adverse outcomes among critically ill patients. We performed a single-center, prospective cohort study among 121 critically ill patients admitted to intensive care units (ICUs) between 2008 and 2012. We measured plasma hCAP18, 25D, D-binding protein, and parathyroid hormone levels on ICU day 1. The primary endpoint was 90-day mortality. Secondary endpoints included hospital mortality, sepsis, acute kidney injury, duration of mechanical ventilation, and hospital length of stay. ICU day 1 hCAP18 levels were directly correlated with 25D levels (Spearman's rho (rs) = 0.30, P = 0.001). In multivariate analyses adjusted for age and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, patients with hCAP18 levels in the lowest compared to highest tertile on ICU day 1 had a 4.49 (1.08 to 18.67) greater odds of 90-day mortality, and also had greater odds of sepsis. ICU day 1 levels of other analytes were not associated with 90-day mortality. Lower 25D levels on ICU day 1 are associated with lower hCAP18 levels, which are in turn associated with a greater risk of 90-day mortality. These findings provide a potential mechanistic basis for the frequently observed association between low 25D levels and poor outcomes in critically ill patients.
Stephanie A. Regan, Sciprofile linkRosanna Marsella, Sciprofile linkIbrahim Ozmen
Case Reports in Veterinary Medicine, Volume 2015, pp 1-4; doi:10.1155/2015/912509

Abstract:
Psoriasis manifests as chronic dermatitis and arthritis (PsA) in people. Psoriasis with concurrent PsA is characterized by erythematous, silvery, scaly plaques, especially on the extremities, and concurrent arthritis with enthesitis, tenosynovitis, and dactylitis. To date, no such disease has spontaneously occurred in domestic animals. This case report aims to describe the clinical, radiographic, and histologic appearance of a psoriasis-like dermatitis and psoriatic-like arthritis in a dog. A 4-year-old female spayed pug mix presented for the evaluation of chronic history of hyperkeratotic footpads and deforming arthritis. After ruling out other differential diagnoses and based on the similarity of clinical, radiographic, and histologic findings to human psoriasis and PsA, a tentative diagnosis of psoriasis-like disease was made. Treatment was begun to control pain (tramadol, gabapentin, and carprofen) and psoriatic dermatitis (clobetasol propionate 0.05%, calcipotriene 0.005%, and urea 40% ointment twice daily). Dramatic positive response to treatment was achieved confirming the tentative diagnosis. This case may provide preliminary evidence for the existence of a psoriasis-like condition in dogs and may elucidate treatment options in otherwise refractory cases of chronic dermatitis and polyarthropathy in dogs.1. IntroductionPsoriasis is a very common and frustrating disease in people that can have both cutaneous and bone manifestations. Interestingly there has been no report, so far, of spontaneously occurring psoriasis-like disease in domestic animals. The reasons for this difference are not known. In this report we describe the first case of a psoriasis-like disease in a dog that presented with both cutaneous and bone signs. The dog of this case report had not responded to treatments prescribed for the various conditions known in veterinary medicine attempting to make her fit in what is known in animals. Thus she had been unsuccessfully managed for a long time as it did not fit in any previously described diseases of dogs. To the dog’s benefit, a human dermatologist happens to be available for assessment and a diagnosis of psoriasis-like disease was made as the changes found in this dog appeared to be classic for how the disease presents in people. The purpose of this report is to make practitioners aware that although this psoriasis-like condition may be very rare in dogs, it can develop and it seems to respond to the same treatments reported in human medicine.2. Case PresentationA 4-year-old female spayed pug mix weighing 8.7 kg presented for a two-year history of chronic, hyperplastic, crusting, parakeratotic pododermatitis, intermittent episodes of lethargy and minimal weight bearing on all four limbs. The dog had ability to ambulate but was reluctant to do so especially on hard surfaces. There was soft tissue swelling associated with multiple digits of every foot. The dog had been adopted at age 2 with the above symptoms already present; thus the exact age of onset of clinical signs was not known.When presented to the referring veterinarian (rDVM) at 2 years old, the original diagnosis was interdigital pododermatitis and cellulitis on all four limbs with almost all digits involved. Clinical differentials by rDVM included necrolytic migratory erythema (NME), pemphigus foliaceus, and chronic footpad hyperkeratosis, but the joint changes and soft tissue swelling did not fit any of these differentials. Radiographs confirmed soft tissue swelling and revealed periosteal proliferations suggesting chronic periosteitis. Blood work did not reveal any abnormalities. Oral enrofloxacin and cephalexin were begun as well as debridement, flush, topical antibiotic ointment, and bandaging of the footpads. Pain was controlled with metacam liquid. At the one-month recheck, there was no response to treatment and worsening in condition had occurred despite oral antibiotics. Therapy was changed to tetracycline, prednisone, and niacinamide as well as cold laser therapy. Skin biopsy was performed and showed severe hyperplastic parakeratotic hyperkeratosis with infiltration of lymphocytes and plasma cells and a smaller population of neutrophils, mast cells, and macrophages.The dog was then referred to a local dermatologist who performed a toe amputation for additional biopsy and culture and sensitivity. Biopsy showed marked acanthosis with formation of papillae, parakeratosis, and multiple pustules and parakeratotic microabscesses and crust formation. The crust was composed by necrotic cellular debris and neutrophils. No acantholysis and no primary etiologic agents were detected. In the biopsy a moderate amount of chronic active neutrophilic, superficial perivascular pododermatitis was present. Bacterial culture showed scant growth of Staphylococcus pseudintermedius sensitive to cephalosporins. While some of these features were consistent with metabolic epidermal necrosis (e.g., severe parakeratotic hyperkeratosis), there was no inter- or intracellular edema. Blood work was repeated (CBC, chemistry panel, and TT4) and was within normal limit. Diagnosis was again presumptive NME or zinc responsive dermatitis although many of the features of this disease were not found in the patient. This dog had no evidence of other liver or pancreatic diseases and was fed a well-balanced commercial diet. Other differential diagnoses included idiopathic chronic hyperkeratosis of footpads but no explanation was provided for the combination of dermatitis and deforming arthritis and bone changes. Medications and therapy were modified to a one-month course of Cefpodoxime proxetil (Simplicef), amino blend dietary supplement, zinc methionine, omega 3 fatty acids, egg yolk supplement, and a high protein diet to address any dermatitis linked to amino acid or zinc deficiency and carprofen (Rimadyl) and tramadol for pain management. This therapy did not lead to any clinical improvement after one month; thus the dog was then referred to UF.On presentation to UF Dermatology at the veterinary school, the patient was quiet, alert, and responsive but reluctant to ambulate. Her cardiothoracic auscultation and physical exam parameters were within normal limits. Dermatologic examination revealed severe hyperkeratosis on footpads (Figure 1) on all four limbs. All four feet palpated with a positive pain response. The rDVM provided radiographs which showed proliferative joint disease in the interphalangeal joints of forelimbs (Figure 2). Major differentials based on history and previous diagnostics were again NME, possibly due to liver disease, glucagonoma, and GI malabsorption. However, these differentials still failed to explain the arthritis component, intermittent lethargy, solely digital distribution of lesions, and the early onset of symptoms (age 2 or potentially earlier) and were not consistent with any previous blood work which had all been within normal limits.Figure 1: Photograph before treatment of worst affected digit, featuring soft tissue swelling, proliferative arthritis, and hyperkeratosis.Figure 2: Radiographs of forelimbs before treatment, showing proliferative joint disease in the interphalangeal joint, ankylosis, dactylitis, and enthesitis.NME is frequently linked to liver changes; thus, in the attempt to further pursue NME, ultrasound was performed but findings were unremarkable. Pancreatic Lipase Immunoreactivity (PLI) and Trypsin-Like Immunoreactivity (TLI) were discussed as diagnostic options to further investigate other possible cases of NME but not pursued at first visit in light of the complete absence of clinical signs to support this differential diagnosis.Upon further examination of the confluence of clinical signs, biopsy results, and radiographic changes noted and in consultation with a human dermatologist, it was determined that plaque psoriasis with psoriatic arthritis, although neither was ever previously documented in canines, could actually provide a comprehensive explanation for the condition of this dog. Thus, a tentative diagnosis of psoriatic-like disease was made and it was decided to attempt first line of defense therapy for psoriasis as it would be done in human medicine.Treatment was begun based on a presumptive diagnosis of psoriatic-like arthritis and consisted of tramadol (25 mg q6-8hr PRN for pain), gabapentin (100 mg q8hr for pain), and carprofen (25 mg q24hr for pain, arthritis, and inflammation). To control the dermatologic symptoms clobetasol propionate 0.05% ointment (topical steroid), calcipotriene 0.005% ointment (topical Vitamin D), and urea 40% ointment (topical keratolytic) were prescribed to be used twice daily, with one of the daily administrations to be performed under occlusion. To properly perform occlusion therapy, Pawz dog boots (Figure 3) were given to provide a soft, water-vapor impermeable membrane that would be easily applicable to the paws. Topical therapy was prescribed until reexamination with the possibility of adding systemic therapy with oral steroids (prednisone) or oral disease modifying antirheumatic drugs (methotrexate, also classified as an antimetabolite immunosuppressant) later on, if needed. Follow-up care was performed at the rDVM with consultation by UF Dermatology. rDVM noted on follow-up communication that the patient responded beautifully to topical treatment; crusting of footpads was reduced and the patient’s comfort and activity level had dramatically increased. While she was reluctant to ambulate at all previously, she was now comfortable and even observed to initiate play several times. At two-month follow-up some muscle wasting was noticed, and topical treatment was reduced in frequency. Muscle wasting resolved following these changes. Owners were very satisfied with improvement in quality of life, and no systemic treatments were needed. One year later she is currently being maintained with carprofen and tramadol if needed, 1 capsule of Omega Tri-V PO q24hr, clobetasol
Rajeshwari S Vhora, Avinash Munde, Charan Bale, Arjun Lal Kakrani
Medical Journal of Dr. D.Y. Patil University, Volume 8; doi:10.4103/0975-2870.169947

The publisher has not yet granted permission to display this abstract.
BMC Cardiovascular Disorders, Volume 14; doi:10.1186/1471-2261-14-156

Abstract:
Vitamin D deficiency is associated with cardiovascular (CV) risk in multiple populations, including those with chronic kidney disease (CKD). The active form of the hormone (1,25 OH2D3) binds to receptors in multiple organs. CKD patients are deficient in both 25 Vitamin D and 1,25 OH2D3. Clinical trial data demonstrating the benefits of vitamin D formulations are limited, and fail to show significant benefits on CV outcomes, and have compared different compounds, in various populations, and focused on a variety of outcomes. A understanding of the mechanism by which different vitamin D compounds confer CV protection in CKD is important for the design of future studies. This 3 arm randomized prospective double-blinded placebo-controlled study examining the impact of calcitriol (1,25 OH2D3) and 25-hydroxyvitamin D3 supplementation compared to placebo on vascular stiffness, as measured by pulse wave velocity (PWV). Patients are enrolled from 2 tertiary care institutions if they meet inclusion criteria (stable estimated glomerular filtration rate (eGFR) between 15-45ml/min,
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