JAMA dermatology最新文献

Importance: Isotretinoin is the only medical acne treatment capable of inducing acne remission; however, some patients experience acne relapse and require retrials of isotretinoin. There is a need to understand who is most at risk and how daily dose and cumulative dosage can influence outcomes.

Objective: To assess rates of acne relapse and isotretinoin retrial and to identify associated factors among patients with acne who received an isotretinoin treatment course.

Design, setting, and participants: This cohort study used data from the MarketScan commercial claims database from January 1, 2017, to December 31, 2020, to identify patients with acne who were 12 years or older and had received isotretinoin for 4 months or longer, with at least 1 year of continuous enrollment after completion of isotretinoin. Data analyses were performed from June 30, 2024, to August 1, 2024.

Main outcomes and measures: Multivariable Cox proportional hazards regression was used to quantify associations of patient demographic and treatment characteristics with acne relapse and isotretinoin retrial.

Results: A total of 19 907 patients (mean [SD] age, 20.6 [7.8] years; 10 504 females [52.8%]) were included, among whom 4482 (22.5%) had acne relapse and 1639 (8.2%) had isotretinoin retrial. Female sex (hazard ratio [HR], 1.43; 95% CI, 1.35-1.52) was significantly associated with increased rates of acne relapse, and isotretinoin cumulative dosage (mg/kg) was associated with a decreased rate of acne relapse (HR, 0.996; 95% CI, 0.995-0.997). Furthermore, daily dose was not associated with decreased risk of acne relapse or isotretinoin retrial among those with conventional and high cumulative dosages. Female sex (HR, 0.68; 95% CI, 0.62-0.76) and isotretinoin cumulative dosage (HR, 0.99; 95% CI, 0.98-0.99) were associated with decreased rates of isotretinoin retrial. Stratification by cumulative dosage indicated that higher cumulative dosage was associated with decreased rates of retrial among patients with low (<120 mg/kg) and conventional (120-220 mg/kg), but not high (>220 mg/kg) cumulative dosage. Maximum daily dose (mg/kg/d) was not negatively associated with acne relapse or isotretinoin retrial in patients with cumulative dosage of 120 mg/kg or more.

Conclusions and relevance: The findings of this cohort study suggest that higher cumulative dosage may potentially reduce risk of acne relapse and isotretinoin retrial. Furthermore, daily dose was not associated with decreased risk of the outcomes for conventional and high cumulative dosage; therefore, daily dosing could be individualized to patient goals and preferences.

Importance: In the US, Latine patients disproportionately experience severe psoriasis, limited access to care, and poor disease-related quality of life. However, little is known about psoriasis in this growing US population.

Objectives: To explore Latine patients' perception of their illness and their attitudes toward and experiences with the health care system, treatment, and research.

Design, setting, and participants: In this qualitative study, a thematic analysis was performed of in-depth, semistructured interviews of 30 Latine adults with moderate to severe psoriasis at an outpatient dermatology clinic in an urban safety-net hospital. All patients included had psoriasis diagnosed by a dermatologist and were defined as having moderate to severe psoriasis if systemic treatment was offered at any time during their disease course. Interviews were held between July 7 and August 3, 2022. Data saturation was used to determine sample size.

Main outcomes and measures: Interviews were conducted in English or Spanish, audio recorded, transcribed verbatim, and translated. Transcripts were then coded through an iterative process, and themes were identified through thematic analysis.

Results: Among 30 participants included, the mean (SD) age was 50 (11) years, 20 (67%) were male, and 22 (73%) preferred Spanish. Among 15 participants who disclosed their country of origin or ancestry, 7 (23%) were from Mexico; 4 (13%), Guatemala; 2 (7%), El Salvador; 1 (3%), Honduras; 1 (3%), Nicaragua; and 1 (3%), Peru. Six interrelated themes describing participant experiences were identified: (1) illness perception of psoriasis, (2) reliance on sociofamilial connections for medical decision-making, (3) impact of psoriasis on work life, (4) barriers to accessing quality dermatologic care, (5) receptiveness to prescription and nonprescription treatments, and (6) positive perception and interest toward research.

Conclusions and relevance: The findings of this study highlight the impact of psoriasis on Latine individuals, the efforts made by this population to overcome health disparities, their positive perception toward biologic medications, and their interest in participating in biomedical research. Future investigations should assess educational interventions and further explore the preferences of Latine patients toward biologic medications and biomedical research.

Importance: There is growing awareness of the US health sector's substantial contribution to the country's greenhouse gas (GHG) emissions, exacerbating the health threats from climate change. Reducing health care's environmental impact requires understanding its carbon emissions, but there are few published audits of health systems and fewer comprehensive emissions analyses at the clinic or department level.

Objective: To quantify the annual GHG emissions from a large outpatient dermatology practice, compare relative sources of emissions, and identify actionable targets.

Design and setting: This quality improvement study involving a comprehensive carbon footprint analysis (scopes 1-3) of a large (nearly 30 000 visits/y), outpatient medical dermatology practice within the University of Pennsylvania's academic medical complex was conducted following the GHG Protocol Corporate and Corporate Value Chain reporting standards for fiscal year 2022 (ie, July 2021 through June 2022). Data were obtained through energy metering, manual audits, electronic medical records, and administrative data.

Exposure: Data were converted into metric tons of carbon dioxide equivalent (tCO2e), allowing comparison of global-warming potential of emitted GHGs.

Main outcomes and measures: Primary outcomes were tCO2e by scope 1 (direct emissions), scope 2 (indirect, purchased energy), and scope 3 (indirect, upstream/downstream sources), as well as by individual categories of emission sources within each scope.

Results: Scope 3 contributed most to the clinic's carbon footprint, composing 165.5 tCO2e (51.1%), followed by scope 2 (149.9 tCO2e [46.3%]), and scope 1 (8.2 tCO2e [2.5%]). Within scope 3, the greatest contributor was overall purchased goods and services (120.3 tCO2e [72.7% of scope 3]), followed by patient travel to and from the clinic (14.2 tCO2e [8.6%]) and waste (13.1 tCO2e [7.9%]). Steam and chilled water were the largest contributors to scope 2. Clinic energy use intensity was 185.4 kBtu/sqft.

Conclusions and relevance: In this quality improvement study, the composition of emissions at the clinic level reflects the importance of scope 3, paralleling the health sector overall. The lower-resource intensity of the clinic compared to the average energy requirements of the total clinical complex led to a relatively large contribution from scope 2. These findings support efforts to characterize high-yield emissions-reduction targets and allow for identification of actionable, clinic-level steps that may inform broader health system efforts.