Update on the use of topical calcineurin inhibitors in cutaneous lupus erythematosus

Cutaneous manifestations of lupus erythematosus (CLE) are manifold, presenting with unspecific skin manifestations or well-defined clinical dermatological entities. Their relation to each other as well as to systemic lupus erythematosus is variable, yet diagnostically and therapeutically challenging. Therapeutic decisions have to be based on the activity and distribution as well as the type of skin lesions and the extent of systemic disease. Limited skin manifestations may be amply tackled by topical therapy, so far, mainly relying on corticosteroids. In many cases, however, internal treatment has to be combined by using antimalarials, in addition to strict UV-protection. The advent of topical calcineurin inhibitors has contributed substantially to the armamentarium of external treatment options. By specifically interfering with intracytoplasmic signal transduction to activate the nuclear factor of activated T-cells (NF-AT), they are able to modulate various inflammatory mechanisms. The two available compounds, pimecrolimus and tacrolimus, do not induce the skin atrophy characteristic of corticosteroids. They have been studied in a number of case reports, but only in a few randomized, comparative studies. Both are well-tolerated, but differentially effective in the various subsets of CLE. Further studies are needed to directly compare the two compounds to each other, as well as to topical corticosteroids, before final recommendations can be made

Short Term and Long-Term Efficacy of Calcipotriene/ Betamethasone Dipropionate Foam Combination

Psoriasis is a well-known chronic disease characterized by the development of erythematous, indurated, scaly, pruritic plaques on the skin with cycles of remission and symptom flare-ups. The management of patients with chronic plaque psoriasis has been more challenging since the Covid-19 pandemic as health care professionals have had to adapt to remote consultations for some patients, and patients have had to adapt to the changing health landscape. The rapid resolution of psoriasis symptoms especially those with a substantial impact on quality of life can improve patient satisfaction and adherence, making it an important factor in successful treatment. Cal/BD foam contributes to improved patient adherence and treatment outcome through its rapid action and superior efficacy versus Cal or BD monotherapy, Cal/BD ointment and gel and clobetasol cream in the short-term flare treatment of psoriasis. Moreover, the benefits of proactive long-term management of psoriasis compared to reactive management and its favourable safety profile are higher efficacy and a better health-related quality of life. Cal/BD foam should be considered an effective topical treatment for short-term flare treatment and long-term control of adult psoriatic patients

Predictors for early mortality and arrhythmic events in patients with cardiac resynchronization therapy with defibrillator: A two center cohort study

Background: Guidelines of heart failure therapy include cardiac resynchronization as standard ofcare in patients with severely depressed left ventricular function and wide QRS complex. It has beenshown that patients benefit regarding mortality and morbidity. However, early mortality precludes longtermbenefits from the device. The aim of the study was to identify predictors for early occurrence ofboth death and first-ever implantable cardioverter-defibrillator (ICD) therapy using a large combineddatabase of patients with cardiac resynchronization therapy with defibrillator (CRT-D).Methods: From two registries (tertiary care centers) 904 patients were identified, no single patient wasexcluded. Early death was defined as death occurring within the 3 years after implantation whereasearly ICD therapy as such occurring within the first year. 33 baseline parameters were compared usinguni- and multivariate analysis with the Cox model and binary logistic regression.Results: The population was predominantly male (77%), with mean age of 63 ± 11 years and primaryprevention indication in 80%. Mean follow-up was 55 ± 38 months. 256 (28%) patients hadICD therapies whereof the first-ever event occurred early in 52%. 270 (30%) patients died after 41 ±± 31 months, mostly from advancing heart failure (41%), 141 (52%) patients of them early. Independentpredictors for early ICD therapy were secondary prevention and renal failure. Independent predictors forearly mortality were a history of percutaneous coronary intervention and of peripheral vascular disease.Conclusions: Predictors for early mortality after CRT-D implantation were a history of percutaneouscoronary intervention and peripheral vascular disease, present in only a minority of patients, thus limitingtheir use in clinical practice

Quantitative assessment of a second-generation cryoballoon ablation catheter with new cooling technology—a perspective on potential implications on outcome

Purpose: The purpose of this study was to assess the differences in cooling behavior between the first-generation cryoballoon (CB-1G) and the second-generation cryoballoon (CB-2G) quantitatively to understand the freezing capabilities and to benefit from the improved efficacy of the CB-2G in patients with atrial fibrillation. Methods: We analyzed quantitatively the ice formation of the CB-1G and CB-2G catheters in vitro in a 37°C warm water bath during freezing for 60, 120, 180, 240, and 300s, respectively. Results: The mean-covered surface area and the relative coverage of the ice spots on the CB-2G were significantly different from the spots on the CB-1G for the 28-mm CBs but not for the 23-mm CBs. Whereas for the CB-1G, the ice formation was discontiguous with four isolated ice spots; the CB-2G showed a contiguous ice cap covering the entire distal part including the pole of the balloon. No homogeneous cooling behavior could be observed at the equatorial level with both catheters. Temporal differences on the ice formation could be observed for the 28-mm CB-2G but not for the 23-mm CB-2G. Conclusion: The new-generation CB-2G showed more powerful and homogeneous cooling behavior, especially for the 28-mm CB. Whether this translates into higher long-term success rates is currently unknown. The impact of the more effective cooling and the longer dissolving duration of the ice cap of the new-generation CB-2G on procedural safety needs to be investigated

Phrenic nerve palsy during ablation of atrial fibrillation using a 28-mm cryoballoon catheter: predictors and prevention

Purpose: The purposes of this study were to determine whether predictors of phrenic nerve palsy (PNP) exist and to test whether a standardized ablation protocol may prevent PNP during cryoballoon (CB) ablation using the 28mm CB. Methods: Three-dimensional (3D) geometry of the pulmonary veins (PV) and their relationship to the superior vena cava (SVC) was analyzed. Phrenic nerve (PN) stimulation was performed during ablation of the right-sided PVs with a 28-mm CB. The freezing cycle was immediately terminated in case of loss of PN capture. Results: Sixty-five patients (age, 58 ± 11years; ejection fraction, 0.59 ± 0.06; left atrial size, 40 ± 5mm) with paroxysmal atrial fibrillation were included. No persistent PNP was observed. Transient PNP occurred in 4 of 65 patients (6%). PN function normalized within 24h in all four patients. A short distance between the right superior PV and the SVC was significantly associated with PNP, but left atrial and 3D PV anatomy were not. Low temperature early during the freezing cycle (<−41°C at 30s) predicted PNP with a sensitivity and a specificity of 100 and 98%, respectively. Conclusion: The anatomical relationship between the right superior PV and the SVC is a preprocedural predictor for the development of transient PNP, and low temperature early during ablation at the right superior PV is a sensitive warning sign of impending PNP. Despite the use of the 28mm CB, transient PNP occurred in 6% of patients undergoing CB ablatio

High-sensitivity cardiac Troponin T delta concentration after repeat pulmonary vein isolation

Introduction: Difference between high-sensitivity cardiac troponin T concentrations (hs-cTnT) before and after ablation procedure (delta concentration) reflects the amount of myocardial injury. The aim of the study was to investigate hs-cTnT prognostic power for predicting atrial fibrillation (AF) recurrence after repeat pulmonary vein isolation (PVI) procedure. Materials and methods: Consecutive patients with paroxysmal AF undergoing repeat PVI using a focal radiofrequency catheter were included in the study. Hs-cTnT was measured before and 18-24 hours after the procedure. Standardized 3, 6 and 12-month follow-up was performed. Cox-regression analysis was used to identify predictors of AF recurrence. Results: A total of 105 patients undergoing repeat PVI were analysed (24% female, median age 61 years). Median (interquartile range) hs-cTnT delta after repeat PVI was 283 (127 - 489) ng/L. After a median follow-up of 12 months, AF recurred in 24 (23%) patients. A weak linear relationship between the total radiofrequency energy delivery time and delta hs-cTnT was observed (Pearson R2 = 0.31, P = 0.030). Delta Hs-cTnT was not identified as a significant long-term predictor of AF recurrence after repeated PVI (P = 0.920). Conclusion: This was the first study evaluating the prognostic power of delta hs-cTnT in predicting AF recurrence after repeat PVI. Delta hs-cTnT does not predict AF recurrence after repeat PVI procedures. Systematic measurement of hs-cTnT after repeat PVI does not add information relevant to outcome

Effective reduction of fluoroscopy duration by using an advanced electroanatomic-mapping system and a standardized procedural protocol for ablation of atrial fibrillation: ‘the unleaded study'

Aims It is recommended to keep exposure to ionizing radiation as low as reasonably achievable. The aim of this study was to determine whether fluoroscopy-free mapping and ablation using a standardized procedural protocol is feasible in patients undergoing pulmonary vein isolation (PVI). Methods and results Sixty consecutive patients were analysed: Thirty consecutive patients undergoing PVI using Carto3 were treated using a standardized procedural fluoroscopy protocol with X-ray being disabled after transseptal puncture (Group 1) and compared with a set of previous 30 consecutive patients undergoing PVI without a specific recommendation regarding the use of fluoroscopy (Group 2). The main outcome measures were the feasibility of fluoroscopy-free mapping and ablation, total fluoroscopy time, total dose area product (DAP), and procedure time. Sixty patients (age 60 ± 10 years, 73% male, ejection fraction 0.55 ± 0.09, left atrium 42 ± 8 mm) were included. In Group 1, total fluoroscopy time was 4.2 (2.6-5.6) min and mapping and ablation during PVI without using fluoroscopy was feasible in 29 of 30 patients (97%). In Group 2, total fluoroscopy time was 9.3 (6.4-13.9) min (P < 0.001). Total DAP was 13.2 (6.2-22.2) Gy*cm2 in Group 1 compared with 17.5 (11.7-29.7) Gy*cm2 in Group 2 (P = 0.036). Total procedure time did not differ between Groups 1 (133 ± 37 min) and 2 (134 ± 37 min, P = 0.884). Conclusion Performing mapping and ablation guided by an electroanatomic-mapping system during PVI without using fluoroscopy after transseptal puncture using a standardized procedural protocol is feasible in almost all patients and is associated with markedly decreased total fluoroscopy duration and DA

Diagnostic value of tachycardia features and pacing maneuvers during paroxysmal supraventricular tachycardia

AbstractOBJECTIVESThe purpose of this prospective study was to quantitate the diagnostic value of several tachycardia features and pacing maneuvers in patients with paroxysmal supraventricular tachycardia (PSVT) in the electrophysiology laboratory.BACKGROUNDNo study has prospectively compared the value of multiple diagnostic tools in a large group of patients with PSVT.METHODSOne hundred ninety-six consecutive patients who had 200 inducible sustained PSVTs during an electrophysiology procedure were included. The diagnostic values of four baseline electrophysiologic parameters, nine tachycardia features and five diagnostic pacing maneuvers were quantified.RESULTSThe only tachycardia characteristic that was diagnostic of atrioventricular (AV) nodal reentry was a septal ventriculoatrial (VA) time of <70 ms, and no pacing maneuver was diagnostic for AV nodal reentry. An increase in the VA interval with the development of a bundle branch block was the only tachycardia characteristic that was diagnostic for orthodromic tachycardia, but it occurred in only 7% of all tachycardias. An atrial-atrial-ventricular response upon cessation of ventricular overdrive pacing was diagnostic of atrial tachycardia, and this maneuver could be applied to 78% of all tachycardias. Burst ventricular pacing excluded atrial tachycardia when the tachycardia terminated without depolarization of the atrium, but the result could be obtained only in 27% of patients.CONCLUSIONSThis prospective study quantitates the diagnostic value of multiple observations and pacing maneuvers that are commonly used during PSVT in the electrophysiology laboratory. The findings demonstrate that diagnostic techniques rarely provide a diagnosis when used individually. Therefore, careful observations and multiple pacing maneuvers are often required for an accurate diagnosis during PSVT. The results of this study provide a useful reference with which new diagnostic techniques can be compared