Therapeutic inertia during isotretinoin treatment of juvenile acne by dermatologists, paediatricians and general practitioners

BACKGROUND

Isotretinoin is an effective treatment for severe juvenile acne, but it appears to be underused in relation to the recommendations. Therapeutic inertia is defined as a failure to initiate or intensify treatment even when warranted by the recommendations. The aim of this study was to investigate therapeutic inertia among dermatologists (D), paediatricians (P), and general practitioners (GPs) in initiating isotretinoin for moderate-to-very severe juvenile acne.

METHODS

Data were collected using a questionnaire distributed to French physicians through medical societies via Internet. The questions explored the role in inertia of factors related to physicians, patients, parents, and the healthcare system, and evaluated barriers and facilitators to prescribing isotretinoin.

RESULTS

In all, 768 physicians responded to the survey (528 D, 178P, and 61 GPs; mean age: 51 years; women: 78 %). Their responses revealed that 99 % of dermatologists felt comfortable prescribing isotretinoin, compared with 8 % and 15 % of paediatricians and GPs (p < 0.05); 93 % of dermatologists were aware of the current guidelines compared with 37 % of paediatricians and GPs. Under 50 % of the physicians had received training on acne in the previous 3 years, regardless of specialty. The most frequently identified factors for inertia were concerns over the psychological consequences of the treatment in adolescents, exclusive requests from parents, and patient unavailability. Paediatricians reported having insufficient knowledge of current recommendations, a lack of training, and a tendency to anticipate poor compliance. Paediatricians and GPs considered that access to first-time prescriptions and peer-to-peer exchanges would constitute facilitating factors in their use of isotretinoin.

DISCUSSION

Concerns over the psychiatric consequences of isotretinoin in adolescents, the need for frequent follow-up, and lack of continuing medical education were identified as factors favouring inertia in the initiation of isotretinoin treatment in patients with moderate-to-very severe juvenile acne, particularly among paediatricians and GPs. Potential strategies to overcome these barriers include regular training, simplified recommendations in French, and access to first-time prescription for paediatricians and GPs.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

[Scurvy presenting with low-extremity necrotic and purpuric ulcers: Two cases]

BACKGROUND

Scurvy is a clinical syndrome resulting from ascorbic acid deficiency. Although presently rare in the developed world, it continues to occur within certain susceptible populations, particularly the elderly and those with dietary habits with low vitamin C intake.

CASES

Two men aged 87 and 69 were referred with multifactorial, progressive ulceration of the lower limbs, without scarring, in a context of arterial disease and other associated comorbidities. In both cases, the level of vitamin C was undetectable. An improvement in the necrotic component and in the purpura was promptly observed after vitamin C supplementation.

CONCLUSIONS

Diagnosis of scurvy can be challenging. This report highlights the importance of maintaining a high index of suspicion for scurvy in atypical necrotic ulcerations of lower extremities with poor response to standard therapy especially in populations at high risk of vitamin C deficiency. Early diagnosis can improve patient prognosis.