Karen E. Huang

Frequency of Primary Nonadherence to Acne Treatment

IMPORTANCE Treatment outcomes depend on adherence to the prescribed regimen. Primary nonadherence refers to not obtaining and starting to take a prescribed medication. The frequency of primary nonadherence to acne treatment has not been well characterized. The complexity of multidrug acne regimens may add to this problem but, to our knowledge, has not been explored. OBJECTIVES To estimate acne treatment primary nonadherence rates and to determine the relationship between primary nonadherence and the number of acne treatments prescribed. DESIGN, SETTING, AND PARTICIPANTS A review of medical records from an outpatient university dermatology clinic identified patients with an acne diagnosis at a dermatology visit in the past 3 months who were prescribed 1, 2, or 3 or more treatments. Patients were excluded if they were not English speakers, were not prescribed treatment for their acne, or did not have an active telephone number. Using randomized lists, these patients were queried via telephone regarding which acne treatments they obtained. The results were analyzed using Fisher exact tests and multivariable logistic regression. For patients who were prescribed 1, 2, or 3 or more treatments, 47, 48, and 48 eligible patients were contacted, respectively. MAIN OUTCOMES AND MEASURES The primary study outcomes were the overall rate of primary nonadherence and the rate for each treatment-number subgroup. Secondary outcomes included the association of sex, age, medication type, and electronic prescription status with primary nonadherence. RESULTS Overall, 27% of patients did not fill all their prescriptions. Of patients who were given 1, 2, or 3 or more treatments, 9%, 40%, and 31%, respectively, did not fill all their prescriptions. There was no statistically significant difference by sex or age for primary nonadherence in any of the 3 treatment-number groups. Based on multivariable analyses, being prescribed a topical retinoid (odds ratio, 2.9; 95% CI, 1.0-8.0) or an over-the-counter product (odds ratio, 3.6; 95% CI, 1.1-12.3) was associated with primary nonadherence. Based on univariate analysis, there was less primary nonadherence with electronic prescriptions compared with paper prescriptions (P < .001). CONCLUSIONS AND RELEVANCE Primary adherence to an acne treatment regimen is better when only 1 treatment is prescribed. Some patients may not complete acne treatment because 1 or more of their medications were never obtained.

Surge in US outpatient vitamin D deficiency diagnoses: National Ambulatory Medical Care Survey analysis.

Objectives In light of the growing medical interest in the potential consequences of vitamin D deficiency, it is important that clinicians are informed about the varying factors that may complicate the assessment of vitamin D status and the diagnosis of deficiency. To better understand the frequency of vitamin D deficiency diagnoses in the ambulatory setting over time, the objective of this investigation was to examine unspecific, general, and bone-related vitamin D deficiency diagnoses between 2007 and 2010 and to determine whether the rate of diagnoses differed by patient age and sex. Methods We used data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to assess the rate of vitamin D deficiency diagnoses provided between 2007 and 2010 during outpatient visits with nonfederally employed physicians in offices and hospitals. Two hundred ninety-two unweighted patient visit records were included. Trends in vitamin D deficiency diagnosis over time, diagnosis of bone disease associated with a vitamin D deficiency diagnosis, and patient age and sex were reported. Results The number of diagnoses for vitamin D deficiency rapidly increased from 2007 to 2010. More than 97% of diagnoses were for unspecific vitamin D deficiency; 9.6% of vitamin D deficiency visits also resulted in a diagnosis of osteoporosis or bone fracture. Conclusions Although the rate of diagnoses for vitamin D deficiency increased between 2007 and 2010, many diagnoses rendered were for nonspecific disease; therefore, vitamin D deficiency screening may have been ordered for preventive care purposes rather than as a diagnostic aid.

Enteral calcium infusion used successfully as treatment for a patient with hereditary vitamin D resistant rickets (HVDRR) without alopecia: a novel mutation.

BACKGROUND We report a novel mutation in a case of hereditary vitamin D resistant rickets (HVDRR) without alopecia and successful management of this condition with the intravenous formulation of calcium chloride delivered via gastric tube. CLINICAL CASE A 22 month old male (length -3.4 SDS; weight -2.1 SDS) presented with failure to thrive, short stature, severe hypocalcemia and gross motor delay. He did not have alopecia. Initial blood tests and history were thought possibly to suggest vitamin D deficiency rickets: calcium 5.1mg/dL, (8.8-10.8); phosphorus 4.1mg/dL, (4.5-5.5); alkaline phosphatase 1481 U/L (80-220); intact PTH 537.1 pg/mL (10-71). Subsequently, vitamin D studies returned that were consistent with HVDRR: 25-hydroxyvitamin D 34 ng/mL (20-100); 1,25-dihydroxyvitamin D 507 pg/mL. This diagnosis was confirmed by DNA sequencing. His subsequent clinical course was complicated by the fact that IV calcium was not a viable option for this patient, and his calcium levels could not be well controlled on oral calcium citrate or calcium glubionate therapy. Eventually, we were able to maintain calcium levels above 8 mg/dL using the intravenous preparation of calcium chloride administered via gastric tube. GENETIC STUDIES A unique homozygous T to C base substitution was found in exon 6 in the vitamin D receptor (VDR) gene. This mutation causes leucine to be converted to proline at position 227 in helix 3 in the VDR ligand binding domain (LBD). The mutation rendered the VDR non-functional, leading to HVDRR, with absence of alopecia. CONCLUSION HVDRR should be considered in a patient with profound hypocalcemia which is refractory to conventional therapy of vitamin D deficiency rickets even without evidence of alopecia. We report the first case of HVDRR with a novel mutation in the LBD that was successfully treated with enteral treatment using a calcium chloride infusion.

Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring

Most people with psoriasis have limited disease that could be treated with topicals, but topical efficacy is limited by low short‐term adherence. Psoriasis is a chronic disease, and long‐term adherence is an even bigger problem.

A significant proportion of thalassemia major patients have adrenal insufficiency detectable on provocative testing.

Advances in chelation therapy and noninvasive monitoring of iron overload have resulted in substantial improvements in the survival of transfusion-dependent patients with thalassemia major. Myocardial decompensation and sepsis remain the major causes of death. Although endocrine abnormalities are a well-recognized problem in these iron-overloaded patients, adrenal insufficiency and its consequences are underappreciated by the hematology community. The aims of this study were to determine the prevalence of adrenal insufficiency in thalassemia major subjects, to identify risk factors for adrenal insufficiency, and to localize the origin of the adrenal insufficiency within the hypothalamic-pituitary-adrenal axis. Eighteen subjects with thalassemia major (18.9±9.3 y old, 7 female) were tested for adrenal insufficiency using a glucagon stimulation test. Those found to have adrenal insufficiency (stimulated cortisol <18 µg/dL) subsequently underwent an ovine corticotropin-releasing hormone (oCRH) stimulation test to define the physiological basis for the adrenal insufficiency. The prevalence of adrenal insufficiency was 61%, with an increased prevalence in males over females (92% vs. 29%, P=0.049). Ten of 11 subjects who failed the glucagon stimulation test subsequently demonstrated normal ACTH and cortisol responses to oCRH, indicating a possible hypothalamic origin to their adrenal insufficiency.

The National Ambulatory Medical Care Survey: A resource for understanding the outpatient dermatology treatment

Abstract Background: The National Ambulatory Care Survey (NAMCS) collects information on outpatient medical care in the United States. Key characteristics of the NAMCS methodology are not well recognized. We describe the NAMCS survey design and patient visits to dermatologists and to present information on the validity of the NAMCS data by comparing key features of the dermatologist sample to other surveys of dermatologists. Methods: NAMCS data on dermatologists and skin-related visits from 1993 to 2010 were analyzed and compared to the Dermatology Physician Profile Survey (DPPS), a survey by the American Academy of Dermatology. Results: A total of 29 554 patient visits to dermatologists were sampled from 1993 to 2010. On average, 118 dermatologists were sampled annually to participate in the NAMCS, and response rates ranged from 47 to 77%. The NAMCS and the DPPS found similar dermatologist demographics, practice settings and reimbursement sources. Conclusion: Overall, the NAMCS achieves high-response rates and provides a generalizable sample that has been used in scores of studies of dermatology outpatient treatment. In a time of changing health care delivery systems, NAMCS is valuable for understanding how physicians care for patients with skin disease.

Measure of Atopic Dermatitis Disease Severity Using Actigraphy

Background: Analyzing adherence to treatment and outcomes in atopic dermatitis is limited by methods to assess continual disease severity. Atopic dermatitis significantly impacts sleep quality, and monitoring sleep through actigraphy may capture disease burden. Purpose: To assess if actigraphy monitors provide continuous measures of atopic dermatitis disease severity and to preliminarily evaluate the impact of a short-course, high-potency topical corticosteroid regimen on sleep quality. Methods: Ten patients with mild to moderate atopic dermatitis applied topical fluocinonide 0.1% cream twice daily for 5 days. Sleep data were captured over 14 days using wrist actigraphy monitors. Investigator Global Assessment (IGA) and secondary measures of disease severity were recorded. Changes in quantity of in-bed time sleep were estimated with random effects models. Results: The mean daily in-bed time, total sleep time, and wake after sleep onset (WASO) were 543.7 minutes (SEM 9.4), 466.0 minutes (SEM 7.7), and 75.0 minutes (SEM 3.4), respectively. WASO, a marker of disrupted sleep, correlated with baseline (ρ = .75) and end of treatment IGA (ρ = .70). Most patients did not have marked changes in sleep. IGA scores declined by a median change of 1 point at days 7 (p = .02) and 14 (p = .008). Conclusions: Using actigraphy, atopic dermatitis disease severity positively correlated with sleep disturbances. Actigraphy monitors were well tolerated by this cohort of atopic dermatitis subjects.

Rosacea patients seeking advice: Qualitative analysis of patients’ posts on a rosacea support forum

Abstract Background: Social media have become outlets for patients to voice opinions and ask questions. Since suffering from rosacea is an isolating experience and the disease is poorly understood, patients use social media to expand their knowledge about the condition. Objective: To understand rosacea patients’ online health information seeking habits to obtain a better insight of their educational needs. Methods: Ten percent of posts in online rosacea forum composed of 3350 members and 27 051 posts, discussing patient viewpoints and concern, selected by stratified random sampling. Three hundred and nine queries were directly categorized to patients “seeking advice” by two investigators and qualitatively analyzed. Results: Patients primarily sought advice about treatments (n = 155, 50.1%), triggers (n = 53, 17.1%), diet (n = 48, 15.5%), skin care (n = 37, 11.9%) and special presentations of the disease (n = 22, 7.1%). Questions frequently pertained to adverse effects, efficacy and target of therapy (78, 49, 30 posts, respectively). Conclusion: Proactively providing reliable resources and comprehensive explanations on treatments, triggers, diet and skin care could be helpful in reducing patients’ confusion about rosacea and enhancing rosacea patient–physician relationships.

Cutaneous cryosurgery in the United States

Abstract Background: Cryosurgery is a common treatment modality for many dermatological conditions; however, the extent to which it is used and by which medical specialties is not well characterized. Objective: To determine the rates of cryosurgery use over time, the top dermatoses treated by cryosurgery, patient demographics and the rate at which practitioners used cryosurgery. Methods: We used the National Ambulatory Medical Care Survey (NAMCS) from 1993 to 2010 in order to quantify the use of cryosurgery in outpatient offices. For visits where cryosurgery was utilized, the leading diagnoses, treating physician specialties, and patient ages were tabulated. Results: Cryosurgery was most commonly used for treating actinic keratoses (48% of visits), seborrheic keratoses (25% of visits) and verrucae (21% of visits). Dermatologists performed 82% of all cryosurgeries, followed by family/internal medicine physicians (13.6%) and pediatricians (2.8%). The use of cryosurgery for these dermatoses has increased over time (p < 0.0001), especially in patients over the age of 65 years. Physicians in offices with health maintenance organization-based practices were more likely to utilize cryosurgery. Limitations: Since NAMCS data are cross-sectional, we are unable to determine whether patients tried and failed other treatments. Conclusions: As the baby boomer generation ages, the demand for cryosurgery will likely further increase.

Prevalence of Rosacea in Community Settings

Background The prevalence of rosacea is poorly characterized. Because selection bias may affect prevalence estimates, there is a need to characterize the prevalence of rosacea outside the clinic setting. Objective To assess the prevalence of rosacea in community settings. Methods A clinical research fellow and a medical student stood in public places (a mall, the Department of Motor Vehicles, a grocery store) and examined consecutive individuals who passed by ≤ 2 yards away. They tallied demographic and descriptive data on the subject and included the subject in one of three categories: clearly rosacea, possible rosacea, and definitely no rosacea. Subanalyses by perceived gender, age, race, and rosacea subtype were also performed. Comparisons between groups were made using the Fisher exact test. Results Considering the prevalence of rosacea among all observed individuals in the community setting, 5.4% (95% CI 3.6-7.8) of individuals had “possible” rosacea and 6% (95% CI 4.1-8.5) of individuals had “definite” rosacea. Older, white individuals with fairer skin types (Fitzpatrick skin types I, II, and III) were more likely to have rosacea. There was no gender predisposition. Limitations Distance from subjects made it difficult to assess patients with mild rosacea or a few telangiectasias, as well as ocular rosacea. The study could not assess those individuals who were too embarrassed by their rosacea to be in the public settings observed. Additionally, some subjects may have applied significant makeup in an effort to conceal their rosacea, making assessment difficult. Conclusions Based on direct observation of individuals in community settings, rosacea is more common than previously reported in the United States.