Metformin for pediatric obesity and insulin resistance: a retrospective study within an integrated health care system.

OBJECTIVE: Few treatments exist for pediatric obesity. Metformin holds potential for pediatric weight loss. This large retrospective study examined the effect of metformin on weight, BMI, BMI z score, and cardiometabolic outcomes. METHODS: The study included 7,068 patients aged 10 to 17 years with BMI at or above the 95th percentile and evidence of insulin resistance. The final cohort of 955 patients with BMI data at 0 to 24 months was categorized into three groups: metformin plus intensive lifestyle changes, intensive counseling alone, and routine counseling. In order to adjust for pubertal BMI changes, a subgroup analysis was conducted for adolescents aged 15 to 17 years. RESULTS: At 6 and 12 months, metformin treatment produced significant reductions in weight (-3.5 kg and -5.3 kg, p < 0.0001), BMI (-1.06 kg/m² and -1.23 kg/m², p < 0.0001), and BMI z score (-0.05 and -0.07, p ≤ 0.002), which continued to decrease at 24 months (-0.05 and -0.08, p = 0.11 and 0.01), compared with control groups. Adolescents aged 15 to 17 years showed similar improvements. Systolic blood pressure and high-density lipoprotein cholesterol also improved in the metformin group. CONCLUSIONS: Metformin with lifestyle interventions significantly reduced weight, BMI, and BMI z score in pediatric patients with obesity and insulin resistance up to 24 months, compared with intensive and routine counseling alone.

Patient Costs Associated with Rosacea.

The recalcitrance of rosacea to many treatment options may prompt patients to spend exorbitant amounts of money on unsubstantiated treatment regimens in an effort to achieve relief. The authors examine the relationship between disease severity and treatment cost across several demographic and socioeconomic strata. Familiarization of evidence-based clinical recommendations and consensus guidelines may equip physicians to educate patients about the most efficacious and cost-effective treatment options to assist patients in making cost-conscious decisions in the management of their rosacea.

Rosacea Patient Perspectives on Homeopathic and Over-the-counter Therapies.

BACKGROUND: Rosacea patients commonly employ nonprescription therapies. The authors' aim was to understand rosacea patients' perceptions of over-the-counter products, complementary and alternative medicine, and homeopathic therapies. METHOD: A public, online discussion forum comprising 3,350 members and 27,051 posts provided a source of 346 posts on patient perceptions on alternative rosacea treatments. RESULTS: Three major themes of nonprescription treatment were identified-motivation for use, patient-provider discussions, and experience with these treatments. Perceived medication failure, barriers to treatment, and distrust of physicians drive patients to seek nonprescription therapies. Still, patients prefer to consult a physician on incorporating nonprescription therapies into treatment. Complementary and alternative medicine natural products (19.4% of posts), complementary and alternative medicine practices (16.5%), and homeopathic medicine (3.8%) were commonly discussed. CONCLUSION: Physicians have an opportunity to be a trusted source of information on the strengths and weaknesses of skin care products and other complementary treatments for rosacea.

Training for prescribing in-office and home phototherapy.

BACKGROUND/PURPOSE: One reason phototherapy use is lacking in the United States may be inadequate phototherapy education during dermatology training. The purpose of this study was to estimate the level of dermatology resident training with prescribing phototherapy and to see whether inadequate education may be contributing to the underuse of phototherapy in the United States. METHODS: A questionnaire was developed to assess resident education and comfort with prescribing phototherapy from the resident perspective. Botulinum toxin and radiation therapy training were used as positive and negative controls, respectively. Responses were tabulated and comparisons made using Fisher's exact test and Cochran-Armitage trend test. RESULTS: A total of 88 residents responded. 42% and 81% of respondents reported not receiving didactic education on prescribing in-office and home phototherapy, respectively, compared to 13% for botulinum toxin and 91% for radiation therapy. 29% and 76% reported not being comfortable prescribing in-office and home phototherapy, respectively, compared to 36% for botulinum toxin and 91% for radiation therapy. Phototherapy education satisfaction was positively correlated with comfort of prescribing, and comfort prescribing was positively correlated with actual prescribing of phototherapy. CONCLUSIONS: Training for prescribing phototherapy is lacking. Augmenting phototherapy training may help make home phototherapy more accessible for patients.

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.

Patient perspectives on low level light therapy and laser therapies for rosacea-associated persistent facial redness.

INTRODUCTION: There are no definitive treatments of facial redness for rosacea. All treatments aim to alleviate symptoms. Patients' perspectives of two emerging modalities, Low level light therapy and laser treatments are not well characterized. The purpose is to further understand rosacea patients unmet needs about these modalities, Methods: The publicly accessible, online rosacea forum was accessed at august 2013. Stratified random sampling method has done to identify a 10% sample of total 27,051 posts. The Posts were published in the "Laser and IPL therapy" and "Low level light therapy" forums were qualitatively analyzed. RESULTS: Patients discussed a variety of topics, but most commonly discussed effectiveness (34.2%), treatment education (19.3%), and adverse effects (18%). Relationship with the health care provider (9.9%), cost (8.1%), execution of treatments (8.1%) and convenience of treatments (2.5%) were less commonly discussed, but contributed to patients' decisions about utilizing laser and light therapies. CONCLUSIONS: Online forums are utilized to fulfill patients' desire for educational, empathic and collaborative relationship. Patients' adherence to laser and light therapies will likely increase if costs are reduced, reduction in redness is consistent with their expectations, and if physicians empower them through education on device choices and managing adverse effects.

The effect of folate supplementation on methotrexate efficacy and toxicity in psoriasis patients and folic acid use by dermatologists in the USA.

BACKGROUND: Methotrexate (MTX) is an effective treatment for psoriasis but its use is limited by its toxicity. Folate supplementation can be used to reduce the adverse effects of MTX, though this may impact efficacy. The frequency of folic acid supplementation is not well characterized. PURPOSE: The objective of this study was to review the literature involving the use of folate in patients (in particular those with psoriasis) treated with MTX and analyze trends in folic acid use. METHODS: We searched PubMed from 1 May 1989 through 1 April 2012 using the terms 'folic acid,' 'folinic acid,' 'folate,' 'supplementation,' and 'methotrexate.' We also used the National Ambulatory Medical Care Survey (NAMCS) database to collect data regarding trends in MTX use and folic acid supplementation by physicians in the USA from 1993 through 2009. We assessed data including the number of MTX visits, rate of folic acid use, diagnoses, physician specialty, and demographics of patients. We used linear regression to analyze the change in folic acid use over time. RESULTS: Twenty-six published trials were included addressing folic acid supplementation with MTX. The majority found a benefit to folic acid supplementation, but there were only seven studies in psoriasis. Dermatologists were among the highest prescribers of MTX, and psoriasis was commonly treated with MTX. Folic acid supplementation significantly increased over this time period (p < 0.0001). However, dermatologists ranked lowest for their folate use, co-prescribing folate to only 9.1 % of MTX-treated patients. LIMITATIONS: In contrast to rheumatoid arthritis, there is a scarcity of literature describing the effect of folate on MTX toxicity and efficacy in psoriasis patients. NAMCS data only included outpatient visits to non-federally employed physicians, and there is the possibility of healthcare providers not documenting over-the-counter folic acid usage. Lastly, doses of MTX and folic acid were not recorded in the database. CONCLUSION: Dermatologists were the least likely specialists to supplement MTX with folic acid. The evidence for supplementation of folic acid is mixed. The literature confirms a reduction in the adverse effects of MTX but less strongly that there may be a reduction in efficacy too. Keeping in mind the potential for folate to reduce MTX efficacy, folic acid supplementation should be considered in MTX-treated patients.

Side effects of common acne treatments.

INTRODUCTION: A variety of acne treatments exist, including topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics, hormonal therapy, isotretinoin, and procedural therapies, such as light and laser therapies. Although each of these treatment modalities confer various benefits for the management of acne, it is important for healthcare providers to be aware of their potential side effects, including ones that are most common and most serious, so that these medications can be prescribed in a safe manner. AREAS COVERED: A systematic literature review was performed to identify publications discussing the side effects of the different treatment modalities used for acne vulgaris. Acne treatments reviewed included benzoyl peroxide gel, topical retinoids, topical antibiotics, oral antibiotics, hormonal therapy, isotretinoin, and light/laser treatments. EXPERT OPINION: A comprehensive overview of acne treatments' side effects is imperative for healthcare professionals and scientists working with and prescribing acne treatments. Side effects to be aware of when prescribing range from local irritation with topical treatments to systemic side effects including liver function abnormalities and teratogenic side effects. The best available options are those that address acne severity while minimizing side effects for the patient. Consequently, personalized medicine must be strongly emphasized to healthcare providers developing patients' treatment plans.

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.