NEW YORK – A middle-aged patient with Fitzpatrick type V skin comes to the office with a 10-year history of “breakouts” on her face. When asked about topical treatments, she reports that “everything burns or stings,” and says she just has very sensitive skin. What could this be?

[email protected]

On Twitter @karioakes

NEW YORK – A middle-aged patient with Fitzpatrick type V skin comes to the office with a 10-year history of “breakouts” on her face. When asked about topical treatments, she reports that “everything burns or stings,” and says she just has very sensitive skin. What could this be?

[email protected]

On Twitter @karioakes

NEW YORK – A middle-aged patient with Fitzpatrick type V skin comes to the office with a 10-year history of “breakouts” on her face. When asked about topical treatments, she reports that “everything burns or stings,” and says she just has very sensitive skin. What could this be?

[email protected]

On Twitter @karioakes

Human papillomavirus vaccination in girls and women has increased significantly since the implementation of the Affordable Care Act (ACA), according an analysis of federal survey data.

Overall, girls and women were 3.3 times more likely to receive the vaccine (95% confidence interval, 2.0, 5.5; P less than .0001) in the post–ACA implementation period, compared with the pre-ACA period. They were 5.8 times more likely to receive all three doses of the vaccine (95% CI, 2.5-13.6; P = .0001) post ACA, compared with one dose during that period, according to Rosemary Corriero of the University of Georgia, Athens, who is also a fellow at the Centers for Disease Control and Prevention, and her coauthors (J Pediatr Adolesc Gynecol. 2017 Jul 26. doi: 10.1016/j.jpag.2017.07.002).

xrender/Thinkstock

Human papillomavirus vaccination in girls and women has increased significantly since the implementation of the Affordable Care Act (ACA), according an analysis of federal survey data.

Overall, girls and women were 3.3 times more likely to receive the vaccine (95% confidence interval, 2.0, 5.5; P less than .0001) in the post–ACA implementation period, compared with the pre-ACA period. They were 5.8 times more likely to receive all three doses of the vaccine (95% CI, 2.5-13.6; P = .0001) post ACA, compared with one dose during that period, according to Rosemary Corriero of the University of Georgia, Athens, who is also a fellow at the Centers for Disease Control and Prevention, and her coauthors (J Pediatr Adolesc Gynecol. 2017 Jul 26. doi: 10.1016/j.jpag.2017.07.002).

xrender/Thinkstock

Human papillomavirus vaccination in girls and women has increased significantly since the implementation of the Affordable Care Act (ACA), according an analysis of federal survey data.

Overall, girls and women were 3.3 times more likely to receive the vaccine (95% confidence interval, 2.0, 5.5; P less than .0001) in the post–ACA implementation period, compared with the pre-ACA period. They were 5.8 times more likely to receive all three doses of the vaccine (95% CI, 2.5-13.6; P = .0001) post ACA, compared with one dose during that period, according to Rosemary Corriero of the University of Georgia, Athens, who is also a fellow at the Centers for Disease Control and Prevention, and her coauthors (J Pediatr Adolesc Gynecol. 2017 Jul 26. doi: 10.1016/j.jpag.2017.07.002).

xrender/Thinkstock

The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.

“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.

KatarzynaBialasiewicz/thinkstock

• 36.4% of infants exposed to TDF-FTC-EFV.
• 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
• 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
• 47.4% of infants exposed to ZDV-3TC-NVP.
• 48.5% of infants exposed to TDF-FTC-LPV-R.

The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.

The risk of severe adverse outcomes for ART exposure from conception was as follows:

• 12.3% for exposure to TDF-FTC-EFV.
• 17.9% for exposure to TDF-FTC-NVP.
• 19.5% for TDF-FTC–LPV-R.
• 20.7% for ZDV-3TC-NVP.
• 23.4% for ZDV-3TC–LPV-R.

The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.

“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.

The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.

“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”

The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
 

The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.

“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.

KatarzynaBialasiewicz/thinkstock

• 36.4% of infants exposed to TDF-FTC-EFV.
• 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
• 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
• 47.4% of infants exposed to ZDV-3TC-NVP.
• 48.5% of infants exposed to TDF-FTC-LPV-R.

The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.

The risk of severe adverse outcomes for ART exposure from conception was as follows:

• 12.3% for exposure to TDF-FTC-EFV.
• 17.9% for exposure to TDF-FTC-NVP.
• 19.5% for TDF-FTC–LPV-R.
• 20.7% for ZDV-3TC-NVP.
• 23.4% for ZDV-3TC–LPV-R.

The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.

“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.

The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.

“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”

The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
 

The antiretroviral therapy (ART) regimen associated with the least risk of adverse birth outcomes among pregnant women with HIV, relative to other regimens, is tenofovir disoproxil fumarate (TDF), emtricitabine (FTC), and efavirenz (EFV), according to a new study.

“Our results provide reassurance for the more than 90% of HIV-infected women who live in countries that follow WHO recommendations to use TDF-FTC-EFV,” wrote Rebecca Zash, MD, of Beth Israel Deaconess Medical Center in Boston and her associates in JAMA Pediatrics.

KatarzynaBialasiewicz/thinkstock

• 36.4% of infants exposed to TDF-FTC-EFV.
• 41.7% of infants exposed to TDF-FTC and nevirapine (NVP).
• 44.9% of infants exposed to zidovudine (ZDV), lamivudine (3TC), and lopinavir-ritonavir (LPV-R).
• 47.4% of infants exposed to ZDV-3TC-NVP.
• 48.5% of infants exposed to TDF-FTC-LPV-R.

The risk of adverse birth outcomes, compared with exposure to TDF-FTC-EFV, was 15% higher for TDF-FTC-NVP, 21% higher for ZDV-3TC-LPV-R, 30% higher for ZDV-3TC-NVP, and 31% higher for TDF-FTC-LPV-R after researchers adjusted for age and potential sociodemographic confounders.

The risk of severe adverse outcomes for ART exposure from conception was as follows:

• 12.3% for exposure to TDF-FTC-EFV.
• 17.9% for exposure to TDF-FTC-NVP.
• 19.5% for TDF-FTC–LPV-R.
• 20.7% for ZDV-3TC-NVP.
• 23.4% for ZDV-3TC–LPV-R.

The risk for giving birth to an infant small for gestational age was lowest for TDF-FTC-EFV, compared with the other regimens.

“Differences between TDF-FTC-EFV and other ART regimens were greater for small for gestational age than for preterm birth,” suggesting a “drug-specific mechanism at the placental level because the health of the placenta is directly related to fetal growth,” the researchers wrote. “An ART effect at the level of the placenta may also explain why women receiving ART before conception have more adverse outcomes than [do] those who start ART after conception because endothelial dysfunction during placentation would be expected to have a more detrimental effect on the pregnancy,” they added.

The ZDV-3TC-NVP regimen was linked to greater risk for stillbirth, very preterm birth, and neonatal death; the ZDV-3TC-LPV-R regimen was linked to a greater risk of preterm and very preterm birth, as well as neonatal death.

“Our study findings may be difficult to integrate into settings with ART regimen choices beyond those available in Botswana,” the authors wrote. “Whether the magnitude of the differences we found in Botswana will be similar in higher-resource settings is unclear.”

The research was funded by the National Institutes of Health. The authors reported no conflicts of interest.
 

SAN FRANCISCO – Externalizing problems appear to interfere long term with sleep, whereas sleeping difficulties appear to play a role in children’s development of internalizing problems several years later, new research showed.

“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.

Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.

SAN FRANCISCO – Externalizing problems appear to interfere long term with sleep, whereas sleeping difficulties appear to play a role in children’s development of internalizing problems several years later, new research showed.

“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.

Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.

SAN FRANCISCO – Externalizing problems appear to interfere long term with sleep, whereas sleeping difficulties appear to play a role in children’s development of internalizing problems several years later, new research showed.

“Interventions addressing externalizing difficulties may lead to improvements in sleep, but addressing internalizing difficulties are unlikely to lead to benefits for children’s sleep,” concluded Jon Quach, PhD, of the University of Melbourne and Murdoch Children’s Research Institute, Victoria, Australia, and his colleagues.

Although they also conclude that “addressing sleep problems at earlier time points may reduce both internalizing and externalizing difficulties,” the researchers said the data are inconsistent, only weakly suggesting that sleep influences later externalizing problems at only two different age points, Dr. Quach said when presenting the findings at the Pediatric Academic Societies meeting.

To the Editor:

A 22-year-old obese man with untreated mild asthma diagnosed in childhood presented to the emergency department with cheilitis (Figure 1); conjunctivitis; and painful desquamation of the oral mucosa, penis (Figure 2), and perirectal area (Figure 3). Physical examination was notable for palpebral conjunctiva; mucosal involvement with stomatitis (Figure 1B); and isolated 0.5- to 2-cm erosions and ulcerations with positive Nikolsky sign of the scrotum (Figure 2), trunk, back, and arms and legs. Some areas had evidence of hemorrhagic crust, flaccid bullae, and denudation. Few scant targetoid lesions and dusky red macules on the trunk, face, palms, and soles also were present.

One week prior to presentation he had an episode of diarrhea and dyspnea with symptoms of mild heat stroke after working outdoors, and he self-treated with ibuprofen, which he had taken intermittently for years. He was subsequently seen at an outpatient clinic and was prescribed an albuterol inhaler for previously untreated childhood asthma. The patient stated that he inhaled 2 puffs every 6 hours for a total of 3 treatments. Shortly after the last dose, he noticed a tingling sensation of the oral mucosa that developed into a painful 2-cm bullous ulcer. Over the next 3 days, he developed several more oral ulcers and erosions. Three days before admission he developed dysuria and tense bullae at the glans penis. After admission, he developed cheilitis, conjunctivitis, dysuria, odynophagia, and dysphagia to solids. One day after admission, the patient had the onset of systemic symptoms, including cough with worsening dyspnea, fever, chills, hemoptysis, epistaxis, nausea, diarrhea, loss of appetite, joint pain, and myalgia. Review of systems was otherwise negative. A radiograph was performed at admission and was notable for mild atelectasis but was otherwise normal. The chest radiograph was negative for signs of perihilar lymphadenopathy, pleural effusion, pneumothorax, or lobar infiltrates suggestive of bacterial pneumonia. It also did not show signs of patchy opacities or air bronchograms suggestive of an interstitial pneumonia. On admission, he was started on acyclovir, fluconazole, methylprednisolone, nystatin, pantoprazole, acetaminophen, topical bacitracin, oxycodone, and topical silver nitrate.

At the time of admission our patient was afebrile with a normal heart rate, blood pressure, and respiratory rate. However, he was hypoxic, with a pulse oximetry of 86% on room air and 94% on 40% fraction of inspired oxygen. Complete blood cell count, electrolytes, and liver function tests were all within reference range. Urinalysis revealed evidence of scant red blood cells without pyuria, and the erythrocyte sedimentation rate and creatine kinase level were both elevated. Two blood cultures; sputum cultures; and polymerase chain reaction for Mycoplasma pneumoniae, herpes simplex virus, varicella-zoster virus, cytomegalovirus, and Epstein-Barr virus were negative. Human immunodeficiency virus panel, antinuclear antibody screen, and hepatitis B and C panels were all negative. Four punch biopsies were obtained showing full-thickness epidermal necrosis with neutrophils, few dyskeratotic cells, and sparse inflammatory infiltrate compatible with Stevens-Johnson syndrome (SJS).

After hospital admission, the patient’s mucosal desquamation progressively improved. By day 3, he required minimal supplemental oxygen with resolution of bowel symptoms and improved mucosal and skin findings. He was discharged on day 4 with supplemental oxygen and a 7-day course of prednisone, fluconazole, liquid oxycodone, pantoprazole, and acetaminophen. He showed continued improvement at a follow-up outpatient visit 2 days following discharge.

Stevens-Johnson syndrome is a rare severe drug reaction characterized by high fevers, mucosal erosions, tenderness, and skin detachment approximately 1 to 3 weeks after an inciting event.^1,2 Although SJS has been linked to infections and less commonly to immunizations, in more than 80% of cases, SJS is strongly associated with a recent medication change.³ The classes of drugs that have been implicated in SJS most commonly include antibiotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs.⁴ Stevens-Johnson syndrome from drug reactions is not uncommon; however, SJS secondary to isolated albuterol use is rare.

Although it is presumed that albuterol was the key inciting factor in our patient’s case of SJS, it also is recognized that mucosal SJS can be associated with M pneumoniae infection. For this reason, we performed polymerase chain reaction for M pneumoniae as well as a chest radiograph to rule out this possibility. In addition, our patient had denied prolonged respiratory symptoms suggestive of a mycoplasma pneumonia infection, such as a prodrome of cough, myalgia, headache, sore throat, or fever. A report of 8 patients with documented SJS and M pneumoniae as well as a review of the literature also demonstrated a mean of 10 days of prodromal symptoms prior to the onset of mucosal lesions and/or a rash.⁵ However, mucosal SJS associated with mycoplasma pneumonia is an important clinical entity that should not be forgotten during the workup of a young patient with mucosal lesions or rash suggestive of SJS.

The exact etiology and mechanism of drug-induced SJS is not well understood at this time; however, evidence suggests that SJS is strongly linked to the host’s inability to detoxify drug metabolites.^6,7 It has been postulated that SJS occurs secondary to a cell-mediated immune response, which activates cytotoxic T lymphocytes and subsequently results in keratinocyte apoptosis. Keratinocyte apoptosis occurs via the CD95-CD95 death receptor and soluble or membrane-bound ligand interaction.^3,8,9 Stevens-Johnson syndrome is thought to occur from an interaction involving an HLA antigen–restricted presentation of drug metabolites to cytotoxic T cells, which can be further supported by evidence of strong genetic associations with HLA antigen alleles B15.02 and B58.01 in the cases of carbamazepine- and allopurinol-induced SJS, respectively.^6,7 However, the genetic associations of specific HLA antigen alleles and polymorphisms with SJS and other cutaneous reactions is thought to be drug specific and HLA antigen subtype specific.⁷ Therefore, it is difficult to determine or correlate the clinical outcomes and manifestations of drug reactions in individualized patients. The precise mechanism of antigenicity of albuterol in initiating this cascade has not yet been determined. However, these investigations provide strong evidence for a correlation between specific HLA antigen haplotypes and occurrence of drug antigenicity resulting in SJS and other cutaneous reactions in susceptible patient populations.

Although the specific molecular pathway and etiology of SJS is not well delineated, pathology in combination with clinical correlation allows for diagnosis. Early-stage biopsies in SJS typically show apoptotic keratinocytes throughout the epidermis. Late-stage biopsies exhibit subepidermal blisters and full-thickness epidermal necrosis.¹ Histopathology was performed on 4-mm punch biopsies of the chest and back and demonstrated full-thickness epidermal necrosis with neutrophils and a few dyskeratotic cells, likely representing a late stage of epidermal involvement. Given the predominance of neutrophils, other diagnostic considerations based solely on the biopsy results included contact dermatitis or phototoxic dermatitis. The remaining inflammatory infiltrate was sparse. Immunofluorescence was pan-negative.

This report illustrates a rare case of SJS from isolated albuterol use. This adverse drug reaction has not been well reported in the literature and may be an important consideration in the management of a patient with asthma.

To the Editor:

A 22-year-old obese man with untreated mild asthma diagnosed in childhood presented to the emergency department with cheilitis (Figure 1); conjunctivitis; and painful desquamation of the oral mucosa, penis (Figure 2), and perirectal area (Figure 3). Physical examination was notable for palpebral conjunctiva; mucosal involvement with stomatitis (Figure 1B); and isolated 0.5- to 2-cm erosions and ulcerations with positive Nikolsky sign of the scrotum (Figure 2), trunk, back, and arms and legs. Some areas had evidence of hemorrhagic crust, flaccid bullae, and denudation. Few scant targetoid lesions and dusky red macules on the trunk, face, palms, and soles also were present.

One week prior to presentation he had an episode of diarrhea and dyspnea with symptoms of mild heat stroke after working outdoors, and he self-treated with ibuprofen, which he had taken intermittently for years. He was subsequently seen at an outpatient clinic and was prescribed an albuterol inhaler for previously untreated childhood asthma. The patient stated that he inhaled 2 puffs every 6 hours for a total of 3 treatments. Shortly after the last dose, he noticed a tingling sensation of the oral mucosa that developed into a painful 2-cm bullous ulcer. Over the next 3 days, he developed several more oral ulcers and erosions. Three days before admission he developed dysuria and tense bullae at the glans penis. After admission, he developed cheilitis, conjunctivitis, dysuria, odynophagia, and dysphagia to solids. One day after admission, the patient had the onset of systemic symptoms, including cough with worsening dyspnea, fever, chills, hemoptysis, epistaxis, nausea, diarrhea, loss of appetite, joint pain, and myalgia. Review of systems was otherwise negative. A radiograph was performed at admission and was notable for mild atelectasis but was otherwise normal. The chest radiograph was negative for signs of perihilar lymphadenopathy, pleural effusion, pneumothorax, or lobar infiltrates suggestive of bacterial pneumonia. It also did not show signs of patchy opacities or air bronchograms suggestive of an interstitial pneumonia. On admission, he was started on acyclovir, fluconazole, methylprednisolone, nystatin, pantoprazole, acetaminophen, topical bacitracin, oxycodone, and topical silver nitrate.

At the time of admission our patient was afebrile with a normal heart rate, blood pressure, and respiratory rate. However, he was hypoxic, with a pulse oximetry of 86% on room air and 94% on 40% fraction of inspired oxygen. Complete blood cell count, electrolytes, and liver function tests were all within reference range. Urinalysis revealed evidence of scant red blood cells without pyuria, and the erythrocyte sedimentation rate and creatine kinase level were both elevated. Two blood cultures; sputum cultures; and polymerase chain reaction for Mycoplasma pneumoniae, herpes simplex virus, varicella-zoster virus, cytomegalovirus, and Epstein-Barr virus were negative. Human immunodeficiency virus panel, antinuclear antibody screen, and hepatitis B and C panels were all negative. Four punch biopsies were obtained showing full-thickness epidermal necrosis with neutrophils, few dyskeratotic cells, and sparse inflammatory infiltrate compatible with Stevens-Johnson syndrome (SJS).

After hospital admission, the patient’s mucosal desquamation progressively improved. By day 3, he required minimal supplemental oxygen with resolution of bowel symptoms and improved mucosal and skin findings. He was discharged on day 4 with supplemental oxygen and a 7-day course of prednisone, fluconazole, liquid oxycodone, pantoprazole, and acetaminophen. He showed continued improvement at a follow-up outpatient visit 2 days following discharge.

Stevens-Johnson syndrome is a rare severe drug reaction characterized by high fevers, mucosal erosions, tenderness, and skin detachment approximately 1 to 3 weeks after an inciting event.^1,2 Although SJS has been linked to infections and less commonly to immunizations, in more than 80% of cases, SJS is strongly associated with a recent medication change.³ The classes of drugs that have been implicated in SJS most commonly include antibiotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs.⁴ Stevens-Johnson syndrome from drug reactions is not uncommon; however, SJS secondary to isolated albuterol use is rare.

Although it is presumed that albuterol was the key inciting factor in our patient’s case of SJS, it also is recognized that mucosal SJS can be associated with M pneumoniae infection. For this reason, we performed polymerase chain reaction for M pneumoniae as well as a chest radiograph to rule out this possibility. In addition, our patient had denied prolonged respiratory symptoms suggestive of a mycoplasma pneumonia infection, such as a prodrome of cough, myalgia, headache, sore throat, or fever. A report of 8 patients with documented SJS and M pneumoniae as well as a review of the literature also demonstrated a mean of 10 days of prodromal symptoms prior to the onset of mucosal lesions and/or a rash.⁵ However, mucosal SJS associated with mycoplasma pneumonia is an important clinical entity that should not be forgotten during the workup of a young patient with mucosal lesions or rash suggestive of SJS.

The exact etiology and mechanism of drug-induced SJS is not well understood at this time; however, evidence suggests that SJS is strongly linked to the host’s inability to detoxify drug metabolites.^6,7 It has been postulated that SJS occurs secondary to a cell-mediated immune response, which activates cytotoxic T lymphocytes and subsequently results in keratinocyte apoptosis. Keratinocyte apoptosis occurs via the CD95-CD95 death receptor and soluble or membrane-bound ligand interaction.^3,8,9 Stevens-Johnson syndrome is thought to occur from an interaction involving an HLA antigen–restricted presentation of drug metabolites to cytotoxic T cells, which can be further supported by evidence of strong genetic associations with HLA antigen alleles B15.02 and B58.01 in the cases of carbamazepine- and allopurinol-induced SJS, respectively.^6,7 However, the genetic associations of specific HLA antigen alleles and polymorphisms with SJS and other cutaneous reactions is thought to be drug specific and HLA antigen subtype specific.⁷ Therefore, it is difficult to determine or correlate the clinical outcomes and manifestations of drug reactions in individualized patients. The precise mechanism of antigenicity of albuterol in initiating this cascade has not yet been determined. However, these investigations provide strong evidence for a correlation between specific HLA antigen haplotypes and occurrence of drug antigenicity resulting in SJS and other cutaneous reactions in susceptible patient populations.

Although the specific molecular pathway and etiology of SJS is not well delineated, pathology in combination with clinical correlation allows for diagnosis. Early-stage biopsies in SJS typically show apoptotic keratinocytes throughout the epidermis. Late-stage biopsies exhibit subepidermal blisters and full-thickness epidermal necrosis.¹ Histopathology was performed on 4-mm punch biopsies of the chest and back and demonstrated full-thickness epidermal necrosis with neutrophils and a few dyskeratotic cells, likely representing a late stage of epidermal involvement. Given the predominance of neutrophils, other diagnostic considerations based solely on the biopsy results included contact dermatitis or phototoxic dermatitis. The remaining inflammatory infiltrate was sparse. Immunofluorescence was pan-negative.

This report illustrates a rare case of SJS from isolated albuterol use. This adverse drug reaction has not been well reported in the literature and may be an important consideration in the management of a patient with asthma.

To the Editor:

A 22-year-old obese man with untreated mild asthma diagnosed in childhood presented to the emergency department with cheilitis (Figure 1); conjunctivitis; and painful desquamation of the oral mucosa, penis (Figure 2), and perirectal area (Figure 3). Physical examination was notable for palpebral conjunctiva; mucosal involvement with stomatitis (Figure 1B); and isolated 0.5- to 2-cm erosions and ulcerations with positive Nikolsky sign of the scrotum (Figure 2), trunk, back, and arms and legs. Some areas had evidence of hemorrhagic crust, flaccid bullae, and denudation. Few scant targetoid lesions and dusky red macules on the trunk, face, palms, and soles also were present.

One week prior to presentation he had an episode of diarrhea and dyspnea with symptoms of mild heat stroke after working outdoors, and he self-treated with ibuprofen, which he had taken intermittently for years. He was subsequently seen at an outpatient clinic and was prescribed an albuterol inhaler for previously untreated childhood asthma. The patient stated that he inhaled 2 puffs every 6 hours for a total of 3 treatments. Shortly after the last dose, he noticed a tingling sensation of the oral mucosa that developed into a painful 2-cm bullous ulcer. Over the next 3 days, he developed several more oral ulcers and erosions. Three days before admission he developed dysuria and tense bullae at the glans penis. After admission, he developed cheilitis, conjunctivitis, dysuria, odynophagia, and dysphagia to solids. One day after admission, the patient had the onset of systemic symptoms, including cough with worsening dyspnea, fever, chills, hemoptysis, epistaxis, nausea, diarrhea, loss of appetite, joint pain, and myalgia. Review of systems was otherwise negative. A radiograph was performed at admission and was notable for mild atelectasis but was otherwise normal. The chest radiograph was negative for signs of perihilar lymphadenopathy, pleural effusion, pneumothorax, or lobar infiltrates suggestive of bacterial pneumonia. It also did not show signs of patchy opacities or air bronchograms suggestive of an interstitial pneumonia. On admission, he was started on acyclovir, fluconazole, methylprednisolone, nystatin, pantoprazole, acetaminophen, topical bacitracin, oxycodone, and topical silver nitrate.

At the time of admission our patient was afebrile with a normal heart rate, blood pressure, and respiratory rate. However, he was hypoxic, with a pulse oximetry of 86% on room air and 94% on 40% fraction of inspired oxygen. Complete blood cell count, electrolytes, and liver function tests were all within reference range. Urinalysis revealed evidence of scant red blood cells without pyuria, and the erythrocyte sedimentation rate and creatine kinase level were both elevated. Two blood cultures; sputum cultures; and polymerase chain reaction for Mycoplasma pneumoniae, herpes simplex virus, varicella-zoster virus, cytomegalovirus, and Epstein-Barr virus were negative. Human immunodeficiency virus panel, antinuclear antibody screen, and hepatitis B and C panels were all negative. Four punch biopsies were obtained showing full-thickness epidermal necrosis with neutrophils, few dyskeratotic cells, and sparse inflammatory infiltrate compatible with Stevens-Johnson syndrome (SJS).

After hospital admission, the patient’s mucosal desquamation progressively improved. By day 3, he required minimal supplemental oxygen with resolution of bowel symptoms and improved mucosal and skin findings. He was discharged on day 4 with supplemental oxygen and a 7-day course of prednisone, fluconazole, liquid oxycodone, pantoprazole, and acetaminophen. He showed continued improvement at a follow-up outpatient visit 2 days following discharge.

Stevens-Johnson syndrome is a rare severe drug reaction characterized by high fevers, mucosal erosions, tenderness, and skin detachment approximately 1 to 3 weeks after an inciting event.^1,2 Although SJS has been linked to infections and less commonly to immunizations, in more than 80% of cases, SJS is strongly associated with a recent medication change.³ The classes of drugs that have been implicated in SJS most commonly include antibiotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs.⁴ Stevens-Johnson syndrome from drug reactions is not uncommon; however, SJS secondary to isolated albuterol use is rare.

Although it is presumed that albuterol was the key inciting factor in our patient’s case of SJS, it also is recognized that mucosal SJS can be associated with M pneumoniae infection. For this reason, we performed polymerase chain reaction for M pneumoniae as well as a chest radiograph to rule out this possibility. In addition, our patient had denied prolonged respiratory symptoms suggestive of a mycoplasma pneumonia infection, such as a prodrome of cough, myalgia, headache, sore throat, or fever. A report of 8 patients with documented SJS and M pneumoniae as well as a review of the literature also demonstrated a mean of 10 days of prodromal symptoms prior to the onset of mucosal lesions and/or a rash.⁵ However, mucosal SJS associated with mycoplasma pneumonia is an important clinical entity that should not be forgotten during the workup of a young patient with mucosal lesions or rash suggestive of SJS.

The exact etiology and mechanism of drug-induced SJS is not well understood at this time; however, evidence suggests that SJS is strongly linked to the host’s inability to detoxify drug metabolites.^6,7 It has been postulated that SJS occurs secondary to a cell-mediated immune response, which activates cytotoxic T lymphocytes and subsequently results in keratinocyte apoptosis. Keratinocyte apoptosis occurs via the CD95-CD95 death receptor and soluble or membrane-bound ligand interaction.^3,8,9 Stevens-Johnson syndrome is thought to occur from an interaction involving an HLA antigen–restricted presentation of drug metabolites to cytotoxic T cells, which can be further supported by evidence of strong genetic associations with HLA antigen alleles B15.02 and B58.01 in the cases of carbamazepine- and allopurinol-induced SJS, respectively.^6,7 However, the genetic associations of specific HLA antigen alleles and polymorphisms with SJS and other cutaneous reactions is thought to be drug specific and HLA antigen subtype specific.⁷ Therefore, it is difficult to determine or correlate the clinical outcomes and manifestations of drug reactions in individualized patients. The precise mechanism of antigenicity of albuterol in initiating this cascade has not yet been determined. However, these investigations provide strong evidence for a correlation between specific HLA antigen haplotypes and occurrence of drug antigenicity resulting in SJS and other cutaneous reactions in susceptible patient populations.

Although the specific molecular pathway and etiology of SJS is not well delineated, pathology in combination with clinical correlation allows for diagnosis. Early-stage biopsies in SJS typically show apoptotic keratinocytes throughout the epidermis. Late-stage biopsies exhibit subepidermal blisters and full-thickness epidermal necrosis.¹ Histopathology was performed on 4-mm punch biopsies of the chest and back and demonstrated full-thickness epidermal necrosis with neutrophils and a few dyskeratotic cells, likely representing a late stage of epidermal involvement. Given the predominance of neutrophils, other diagnostic considerations based solely on the biopsy results included contact dermatitis or phototoxic dermatitis. The remaining inflammatory infiltrate was sparse. Immunofluorescence was pan-negative.

This report illustrates a rare case of SJS from isolated albuterol use. This adverse drug reaction has not been well reported in the literature and may be an important consideration in the management of a patient with asthma.

For the second consecutive year, the Mayo Clinic was named the top hospital in the country by U.S. News & World Report.

Also for the second consecutive year, the Cleveland Clinic is ranked second, while Johns Hopkins Hospital in Baltimore and Massachusetts General Hospital in Boston finished third and fourth – switching their places from last year’s ranking – and UCSF Medical Center in San Francisco is fifth after ranking seventh last year, according to the 2017-2018 Best Hospitals ranking.

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For the second consecutive year, the Mayo Clinic was named the top hospital in the country by U.S. News & World Report.

Also for the second consecutive year, the Cleveland Clinic is ranked second, while Johns Hopkins Hospital in Baltimore and Massachusetts General Hospital in Boston finished third and fourth – switching their places from last year’s ranking – and UCSF Medical Center in San Francisco is fifth after ranking seventh last year, according to the 2017-2018 Best Hospitals ranking.

[email protected]

For the second consecutive year, the Mayo Clinic was named the top hospital in the country by U.S. News & World Report.

Also for the second consecutive year, the Cleveland Clinic is ranked second, while Johns Hopkins Hospital in Baltimore and Massachusetts General Hospital in Boston finished third and fourth – switching their places from last year’s ranking – and UCSF Medical Center in San Francisco is fifth after ranking seventh last year, according to the 2017-2018 Best Hospitals ranking.

[email protected]

To the Editor:

Erythema ab igne (EAI) is a reticular erythematous hyperpigmentation of skin repeatedly exposed to moderate heat.¹ It usually is asymptomatic, though some patients report itching or burning at the site.² Historically caused by exposure to coal stoves or open fires, EAI has become increasingly common among individuals using space heaters, heating pads, or laptop computers near bare skin.^2,3 Although EAI itself is benign and usually resolves with the removal of the exposure, it remains of clinical importance because of its association with underlying chronic disease, as chronic pain often is managed with frequent heating pad or hot water bottle use.² Additionally, accurate diagnosis is important given the future risk for malignancy, as chronic changes of EAI have been reported to lead to squamous cell carcinoma or rarely Merkel cell carcinoma.² Erythema ab igne is not traditionally associated with the formation of bullae; however, we present a case of bullous EAI that we believe highlights the importance of including this condition in the differential diagnosis of bullous disorders.

A 55-year-old man was admitted for presumed cellulitis of the bilateral legs. The patient had developed hyperpigmented discoloration of the medial surface of both legs with subsequent formation of tense bullae over the last 2 months. The dermatology department was consulted, as there was concern for bullous pemphigoid. The patient’s medical history was notable for hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and hepatitis C virus with cirrhosis. The patient denied pruritus, pain, or known exposure of the legs to potential irritants prior to developing the lesions; however, with additional questioning he did report frequently sitting in front of a space heater with bare legs. Physical examination revealed multiple areas of reticulated erythematous hyperpigmentation with several overlying bullae (Figure 1). Many of the bullae were unroofed with full-thickness ulceration. Biopsies were taken for hematoxylin and eosin staining (Figure 2) and direct immunofluorescence.

Basic hematologic and metabolic laboratory test results as well as blood cultures were negative. Wound culture was positive for methicillin-resistant Staphylococcus aureus. Histologic examination showed interface dermatitis with subepidermal vesicle (Figure 2). Scattered necrotic keratinocytes were present in the adjacent epidermis, and focal subtle vacuolar alteration of the dermoepidermal junction was seen (Figure 3). Sparse perivascular mononuclear cells and scattered melanophages were present in the dermis. Direct immunofluorescence showed no diagnostic immunopathologic abnormality. Focal weak nonspecific vascular positivity for IgG and C3 was seen, but IgA and IgM were negative. Although not specific, these changes were compatible with EAI in the clinical context provided. The diagnosis of bullous EAI with superimposed staphylococcal infection was made.

Although rare, there have been reports of a bullous variant of EAI. Flanagan et al⁴ described 3 cases of bullous EAI with histopathology similar to our case. All 3 biopsies showed subepidermal separation with a mild perivascular dermal lymphocytic infiltrate. Direct immunofluorescence was negative in 2 cases but showed nonspecific weak patchy deposition of IgM along the dermoepidermal junction.⁴ Although our case was negative for IgM, there was a similar weak nonspecific distribution of IgG. Kokturk et al⁵ described a case of bullous EAI in a man with repeated exposure to a space heater. The lesions showed subepidermal separation of the epidermis; increased elastic fibers; dilated dermal capillaries; melanophages in the upper dermis; and a mild, superficial, perivascular-lymphocytic infiltrate. Direct immunofluorescence showed no immune deposits.⁵ Several earlier cases of bullae associated with EAI have been reported in the literature but were thought to be bullous lichen planus superimposed on EAI.⁶ Our case, which exhibited similar historical, physical, and histopathologic findings, strengthens the argument for a defined bullous variant of EAI.

To the Editor:

Erythema ab igne (EAI) is a reticular erythematous hyperpigmentation of skin repeatedly exposed to moderate heat.¹ It usually is asymptomatic, though some patients report itching or burning at the site.² Historically caused by exposure to coal stoves or open fires, EAI has become increasingly common among individuals using space heaters, heating pads, or laptop computers near bare skin.^2,3 Although EAI itself is benign and usually resolves with the removal of the exposure, it remains of clinical importance because of its association with underlying chronic disease, as chronic pain often is managed with frequent heating pad or hot water bottle use.² Additionally, accurate diagnosis is important given the future risk for malignancy, as chronic changes of EAI have been reported to lead to squamous cell carcinoma or rarely Merkel cell carcinoma.² Erythema ab igne is not traditionally associated with the formation of bullae; however, we present a case of bullous EAI that we believe highlights the importance of including this condition in the differential diagnosis of bullous disorders.

A 55-year-old man was admitted for presumed cellulitis of the bilateral legs. The patient had developed hyperpigmented discoloration of the medial surface of both legs with subsequent formation of tense bullae over the last 2 months. The dermatology department was consulted, as there was concern for bullous pemphigoid. The patient’s medical history was notable for hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and hepatitis C virus with cirrhosis. The patient denied pruritus, pain, or known exposure of the legs to potential irritants prior to developing the lesions; however, with additional questioning he did report frequently sitting in front of a space heater with bare legs. Physical examination revealed multiple areas of reticulated erythematous hyperpigmentation with several overlying bullae (Figure 1). Many of the bullae were unroofed with full-thickness ulceration. Biopsies were taken for hematoxylin and eosin staining (Figure 2) and direct immunofluorescence.

Basic hematologic and metabolic laboratory test results as well as blood cultures were negative. Wound culture was positive for methicillin-resistant Staphylococcus aureus. Histologic examination showed interface dermatitis with subepidermal vesicle (Figure 2). Scattered necrotic keratinocytes were present in the adjacent epidermis, and focal subtle vacuolar alteration of the dermoepidermal junction was seen (Figure 3). Sparse perivascular mononuclear cells and scattered melanophages were present in the dermis. Direct immunofluorescence showed no diagnostic immunopathologic abnormality. Focal weak nonspecific vascular positivity for IgG and C3 was seen, but IgA and IgM were negative. Although not specific, these changes were compatible with EAI in the clinical context provided. The diagnosis of bullous EAI with superimposed staphylococcal infection was made.

Although rare, there have been reports of a bullous variant of EAI. Flanagan et al⁴ described 3 cases of bullous EAI with histopathology similar to our case. All 3 biopsies showed subepidermal separation with a mild perivascular dermal lymphocytic infiltrate. Direct immunofluorescence was negative in 2 cases but showed nonspecific weak patchy deposition of IgM along the dermoepidermal junction.⁴ Although our case was negative for IgM, there was a similar weak nonspecific distribution of IgG. Kokturk et al⁵ described a case of bullous EAI in a man with repeated exposure to a space heater. The lesions showed subepidermal separation of the epidermis; increased elastic fibers; dilated dermal capillaries; melanophages in the upper dermis; and a mild, superficial, perivascular-lymphocytic infiltrate. Direct immunofluorescence showed no immune deposits.⁵ Several earlier cases of bullae associated with EAI have been reported in the literature but were thought to be bullous lichen planus superimposed on EAI.⁶ Our case, which exhibited similar historical, physical, and histopathologic findings, strengthens the argument for a defined bullous variant of EAI.

To the Editor:

Erythema ab igne (EAI) is a reticular erythematous hyperpigmentation of skin repeatedly exposed to moderate heat.¹ It usually is asymptomatic, though some patients report itching or burning at the site.² Historically caused by exposure to coal stoves or open fires, EAI has become increasingly common among individuals using space heaters, heating pads, or laptop computers near bare skin.^2,3 Although EAI itself is benign and usually resolves with the removal of the exposure, it remains of clinical importance because of its association with underlying chronic disease, as chronic pain often is managed with frequent heating pad or hot water bottle use.² Additionally, accurate diagnosis is important given the future risk for malignancy, as chronic changes of EAI have been reported to lead to squamous cell carcinoma or rarely Merkel cell carcinoma.² Erythema ab igne is not traditionally associated with the formation of bullae; however, we present a case of bullous EAI that we believe highlights the importance of including this condition in the differential diagnosis of bullous disorders.

A 55-year-old man was admitted for presumed cellulitis of the bilateral legs. The patient had developed hyperpigmented discoloration of the medial surface of both legs with subsequent formation of tense bullae over the last 2 months. The dermatology department was consulted, as there was concern for bullous pemphigoid. The patient’s medical history was notable for hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and hepatitis C virus with cirrhosis. The patient denied pruritus, pain, or known exposure of the legs to potential irritants prior to developing the lesions; however, with additional questioning he did report frequently sitting in front of a space heater with bare legs. Physical examination revealed multiple areas of reticulated erythematous hyperpigmentation with several overlying bullae (Figure 1). Many of the bullae were unroofed with full-thickness ulceration. Biopsies were taken for hematoxylin and eosin staining (Figure 2) and direct immunofluorescence.

Basic hematologic and metabolic laboratory test results as well as blood cultures were negative. Wound culture was positive for methicillin-resistant Staphylococcus aureus. Histologic examination showed interface dermatitis with subepidermal vesicle (Figure 2). Scattered necrotic keratinocytes were present in the adjacent epidermis, and focal subtle vacuolar alteration of the dermoepidermal junction was seen (Figure 3). Sparse perivascular mononuclear cells and scattered melanophages were present in the dermis. Direct immunofluorescence showed no diagnostic immunopathologic abnormality. Focal weak nonspecific vascular positivity for IgG and C3 was seen, but IgA and IgM were negative. Although not specific, these changes were compatible with EAI in the clinical context provided. The diagnosis of bullous EAI with superimposed staphylococcal infection was made.

Although rare, there have been reports of a bullous variant of EAI. Flanagan et al⁴ described 3 cases of bullous EAI with histopathology similar to our case. All 3 biopsies showed subepidermal separation with a mild perivascular dermal lymphocytic infiltrate. Direct immunofluorescence was negative in 2 cases but showed nonspecific weak patchy deposition of IgM along the dermoepidermal junction.⁴ Although our case was negative for IgM, there was a similar weak nonspecific distribution of IgG. Kokturk et al⁵ described a case of bullous EAI in a man with repeated exposure to a space heater. The lesions showed subepidermal separation of the epidermis; increased elastic fibers; dilated dermal capillaries; melanophages in the upper dermis; and a mild, superficial, perivascular-lymphocytic infiltrate. Direct immunofluorescence showed no immune deposits.⁵ Several earlier cases of bullae associated with EAI have been reported in the literature but were thought to be bullous lichen planus superimposed on EAI.⁶ Our case, which exhibited similar historical, physical, and histopathologic findings, strengthens the argument for a defined bullous variant of EAI.

NEW YORK – When treating patients with skin of color for acne, treatment goals may vary from those of patients with lighter skin, according to Andrew F. Alexis, MD.

For example, in patients with Fitzpatrick skin types V and VI, the desired treatment outcome is not only resolution of acne, but also resolution of hyperpigmentation, said Dr. Alexis, chairman of the department of dermatology at Mount Sinai St. Luke’s and Mount Sinai West, New York, N.Y.

“Postinflammatory hyperpigmentation is often the driving force for the dermatology consult” in individuals with skin of color, Dr. Alexis said at the summer meeting of the American Academy of Dermatology. “They may be just as concerned about their dark spots as underlying acne,” he noted, citing a study that he coauthored (J Clin Aesthet Dermatol. 2014 Jul;7[7]:19-31).

In the study – a survey of patients with acne to determine which treatment outcomes were most important – 41.6% of the nonwhite female patients reported that clearance of postinflammatory hyperpigmentation was the most important goal, compared with 8.4% of white female respondents (P less than .0001).

[email protected]

On Twitter @karioakes

NEW YORK – When treating patients with skin of color for acne, treatment goals may vary from those of patients with lighter skin, according to Andrew F. Alexis, MD.

For example, in patients with Fitzpatrick skin types V and VI, the desired treatment outcome is not only resolution of acne, but also resolution of hyperpigmentation, said Dr. Alexis, chairman of the department of dermatology at Mount Sinai St. Luke’s and Mount Sinai West, New York, N.Y.

“Postinflammatory hyperpigmentation is often the driving force for the dermatology consult” in individuals with skin of color, Dr. Alexis said at the summer meeting of the American Academy of Dermatology. “They may be just as concerned about their dark spots as underlying acne,” he noted, citing a study that he coauthored (J Clin Aesthet Dermatol. 2014 Jul;7[7]:19-31).

In the study – a survey of patients with acne to determine which treatment outcomes were most important – 41.6% of the nonwhite female patients reported that clearance of postinflammatory hyperpigmentation was the most important goal, compared with 8.4% of white female respondents (P less than .0001).

[email protected]

On Twitter @karioakes

NEW YORK – When treating patients with skin of color for acne, treatment goals may vary from those of patients with lighter skin, according to Andrew F. Alexis, MD.

For example, in patients with Fitzpatrick skin types V and VI, the desired treatment outcome is not only resolution of acne, but also resolution of hyperpigmentation, said Dr. Alexis, chairman of the department of dermatology at Mount Sinai St. Luke’s and Mount Sinai West, New York, N.Y.

“Postinflammatory hyperpigmentation is often the driving force for the dermatology consult” in individuals with skin of color, Dr. Alexis said at the summer meeting of the American Academy of Dermatology. “They may be just as concerned about their dark spots as underlying acne,” he noted, citing a study that he coauthored (J Clin Aesthet Dermatol. 2014 Jul;7[7]:19-31).

In the study – a survey of patients with acne to determine which treatment outcomes were most important – 41.6% of the nonwhite female patients reported that clearance of postinflammatory hyperpigmentation was the most important goal, compared with 8.4% of white female respondents (P less than .0001).

[email protected]

On Twitter @karioakes

Girls were more likely than boys to have cardiovascular disease risk factors such as poor aerobic capacity and a high percentage of body fat in a study involving almost 1,800 elementary school students.

Using the FITNESSGRAM Healthy Fitness Zone (HFZ) standards in 1,775 fourth- and fifth-grade students (879 boys, 896 girls) from an urban, predominantly black population, investigators found that significantly more girls than boys did not meet the HFZ for aerobic capacity (71% vs. 42%), percent body fat (53% vs. 30%), and body mass index (44% vs. 34%). Those who did not meet the HFZ for each measure were classified as “needs improvement” or “needs improvement – health risk.”

Overall, more than 66% of the study sample “had metabolic syndrome risk factors based on FITNESSGRAM assessments,” said Susan B. Racette, PhD, of Washington University, St. Louis, and her associates (Prev Med. 2017. doi: 10.1016/j.ypmed.2017.07.032).

More than half of the girls (51%) didn’t meet the HFZ for aerobic capacity and one of the body composition measures, compared with 32% of the boys, and 38% of the girls failed to meet the HFZ for all three measures, compared with 21% of the boys. The reverse side of that coin – those who did meet the HFZ for all three – favored the boys, 46% to 21%, the investigators reported.

“The presence of these cardiovascular disease risk factors in girls, in particular, highlights an important need for creative strategies to mitigate the long-term health and societal consequences of these modifiable risk factors,” Dr. Racette and her associates wrote.

This work was supported by the U.S. Department of Education and the Washington University division of biostatistics. The investigators said that they had no conflicts of interest.

[email protected]

Girls were more likely than boys to have cardiovascular disease risk factors such as poor aerobic capacity and a high percentage of body fat in a study involving almost 1,800 elementary school students.

Using the FITNESSGRAM Healthy Fitness Zone (HFZ) standards in 1,775 fourth- and fifth-grade students (879 boys, 896 girls) from an urban, predominantly black population, investigators found that significantly more girls than boys did not meet the HFZ for aerobic capacity (71% vs. 42%), percent body fat (53% vs. 30%), and body mass index (44% vs. 34%). Those who did not meet the HFZ for each measure were classified as “needs improvement” or “needs improvement – health risk.”

Overall, more than 66% of the study sample “had metabolic syndrome risk factors based on FITNESSGRAM assessments,” said Susan B. Racette, PhD, of Washington University, St. Louis, and her associates (Prev Med. 2017. doi: 10.1016/j.ypmed.2017.07.032).

More than half of the girls (51%) didn’t meet the HFZ for aerobic capacity and one of the body composition measures, compared with 32% of the boys, and 38% of the girls failed to meet the HFZ for all three measures, compared with 21% of the boys. The reverse side of that coin – those who did meet the HFZ for all three – favored the boys, 46% to 21%, the investigators reported.

“The presence of these cardiovascular disease risk factors in girls, in particular, highlights an important need for creative strategies to mitigate the long-term health and societal consequences of these modifiable risk factors,” Dr. Racette and her associates wrote.

This work was supported by the U.S. Department of Education and the Washington University division of biostatistics. The investigators said that they had no conflicts of interest.

[email protected]

Girls were more likely than boys to have cardiovascular disease risk factors such as poor aerobic capacity and a high percentage of body fat in a study involving almost 1,800 elementary school students.

Using the FITNESSGRAM Healthy Fitness Zone (HFZ) standards in 1,775 fourth- and fifth-grade students (879 boys, 896 girls) from an urban, predominantly black population, investigators found that significantly more girls than boys did not meet the HFZ for aerobic capacity (71% vs. 42%), percent body fat (53% vs. 30%), and body mass index (44% vs. 34%). Those who did not meet the HFZ for each measure were classified as “needs improvement” or “needs improvement – health risk.”

Overall, more than 66% of the study sample “had metabolic syndrome risk factors based on FITNESSGRAM assessments,” said Susan B. Racette, PhD, of Washington University, St. Louis, and her associates (Prev Med. 2017. doi: 10.1016/j.ypmed.2017.07.032).

More than half of the girls (51%) didn’t meet the HFZ for aerobic capacity and one of the body composition measures, compared with 32% of the boys, and 38% of the girls failed to meet the HFZ for all three measures, compared with 21% of the boys. The reverse side of that coin – those who did meet the HFZ for all three – favored the boys, 46% to 21%, the investigators reported.

“The presence of these cardiovascular disease risk factors in girls, in particular, highlights an important need for creative strategies to mitigate the long-term health and societal consequences of these modifiable risk factors,” Dr. Racette and her associates wrote.

This work was supported by the U.S. Department of Education and the Washington University division of biostatistics. The investigators said that they had no conflicts of interest.

[email protected]

Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.

“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.

Vonschonertagen/Thinkstock

Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.

“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.

Vonschonertagen/Thinkstock

Nearly one in eight adults in the United States had been diagnosed with alcohol use disorder in 2012-2013, a nearly 50% increase from a decade earlier, according to a study published Aug. 9. Other substantial increases occurring across virtually all demographic groups included overall 12-month alcohol consumption and high-risk drinking, particularly among adults aged 65 and older, racial/ethnic minorities, women, and those with lower education and incomes.

“The marked increases in high-risk drinking and DSM-IV [alcohol use disorder] between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines,” wrote Bridget F. Grant, PhD, of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville, Md., and her associates. High-risk drinking was defined as five drinks (14 g of ethanol each) per occasion for men and four drinks per occasion for women at least weekly.

Vonschonertagen/Thinkstock