Frontal fibrosing alopecia with involvement of the central hair part: distribution of hair loss corresponding to areas of sunscreen application.

Frontal fibrosing alopecia (FFA) typically presents with band-like scarring alopecia in the frontal and temporal hairline along with eyebrow loss. Although this type of hair loss is being seen with increased frequency worldwide, the etiology of the condition is unknown. Studies have suggested a potential environmental role with moisturizers and sunscreens being possible triggers. Herein, we present a 42-year-old woman with a biopsy-proven diagnosis of frontal fibrosing alopecia. In addition to the typical pattern, she also had a striking linear patch of hair loss along her central part. This was an area where she regularly applied sunscreen for many years. Although a causative role for sunscreen ingredients in the development of FFA has not been proven, the evidence accumulated thus far, including our suggestive case, substantiates the need for further study. Additionally, increasing awareness of this potential effect leading to appropriate counseling regarding cessation of possible triggers may be critical for the prevention of further hair loss.

Inappropriate use of antibiotics for acute asthma in United States emergency departments.

OBJECTIVES: The aim was to examine the use of antibiotics to treat asthma patients in U.S. emergency departments (EDs). The authors sought to investigate inappropriate antibiotic prescriptions by identifying the frequency and predictors of antibiotics prescribed for asthma exacerbations using data from two sources, the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Emergency Department Safety Study (NEDSS). METHODS: The authors used data from NHAMCS and NEDSS to identify the proportion of ED visits for asthma exacerbations that resulted in the prescription of an antibiotic. NHAMCS provided national data from 1993 through 2004, while NEDSS provided data from 63 primarily academic EDs from 2003 through 2006. Univariate analysis and multivariate logistic regression modeling were used to identify variables associated with antibiotic administration. RESULTS: Analysis of NHAMCS data revealed that 22% (95% confidence interval [CI] = 20% to 24%) of acute asthma visits resulted in an antibiotic prescription from 1993 through 2004, with no significant change in prescribing frequency over the 12-year period. NEDSS data from 2003 through 2006 showed that 18% (95% CI = 17% to 19%) of acute asthma cases in academic EDs received an antibiotic. Multivariate modeling of NHAMCS data revealed that African American patients (odds ratio [OR] = 0.8; 95% CI = 0.6 to 0.97) and patients in urban EDs (OR = 0.5; 95% CI = 0.4 to 0.7) were less likely to receive antibiotics for asthma exacerbations than white patients and patients in nonurban EDs, respectively. NHAMCS analysis also found that patients in the South were more likely to receive antibiotics than those in the Northeast (OR = 1.4; 95% CI = 1.1 to 1.9). A NEDSS multivariate model found a similar difference, with African Americans (OR = 0.6; 95% CI = 0.4 to 0.8) and Hispanics (OR = 0.6; 95% CI = 0.4 to 0.8) being less likely than whites to receive an antibiotic. CONCLUSIONS: ED treatment of acute asthma with unnecessary antibiotics is likely to contribute to bacterial antibiotic resistance. Interventions are needed to reduce inappropriate antibiotic prescriptions and to address disparities in asthma care.

Declining antibiotic prescriptions for upper respiratory infections, 1993-2004.

OBJECTIVES: To examine antibiotic prescribing trends for U.S. emergency department (ED) visits with upper respiratory tract infections (URIs) between 1993 and 2004. METHODS: Data were compiled from the National Hospital Ambulatory Medical Care Survey (NHAMCS). URI visits were identified by using ICD-9-CM code 465.9, whereas antibiotics were identified using the National Drug Code Directory class Antimicrobials. A multivariate logistic regression model revealed sociodemographic and geographic factors that were independently associated with receipt of an antibiotic prescription for URIs. RESULTS: There were approximately 23.4 million ED visits diagnosed as URIs between 1993 and 2004. Although the proportion of URI diagnoses remained relatively stable (ptrend = 0.26), a significant decrease in provision of antibiotic prescriptions for URIs occurred during this 12-year period, from a maximum of 55% in 1993, to a minimum of 35% in 2004. Patients who were prescribed antibiotics were more likely to be white than African American and to have been treated in EDs located in the southern United States. CONCLUSIONS: Antibiotic prescribing for URIs continues to decrease, a favorable trend that suggests that national efforts to reduce inappropriate antibiotic usage are having some success. Nevertheless, the frequency of antibiotic treatment for URI in the ED remains high (35%). Future efforts to reduce inappropriate antibiotic prescribing may focus on patients and physicians in southern U.S. EDs. Additional work is needed to address continued evidence of race-related disparities in care.

Estimated risk for undiagnosed diabetes in the emergency department: a multicenter survey.

BACKGROUND: One third of the 21 million Americans with diabetes remain undiagnosed. The emergency department (ED) is a novel setting for diabetes screening. OBJECTIVES: To estimate risk factors for undiagnosed diabetes in the ED. METHODS: This was a cross sectional survey in five Boston EDs. The authors enrolled consecutive adults without known diabetes over two 24-hour periods at each site. The focus was on diabetes risk factors and estimated risk for diabetes on the basis of American Diabetes Association (ADA) criteria. The authors also examined prior diabetes testing and willingness to participate in ED-based diabetes screening. RESULTS: Six hundred four patients (70% of eligible) were enrolled. On the basis of ADA risk score, 33% (95% confidence interval [CI] = 29% to 37%) were high risk for undiagnosed diabetes, and an additional 42% (95% CI = 38% to 46%) had elevated risk. For example, 58% (95% CI = 54% to 62%) of participants were overweight or obese (body mass index of > or = 25). Among these at-risk participants without prior diabetes testing, 73% (95% CI = 66% to 80%) reported amenability to having additional blood drawn for ED diabetes screening, and 98% (95% CI = 96% to 100%) indicated that they would follow up for confirmation of abnormal screening. CONCLUSIONS: Many ED patients in the study had risk factors for undiagnosed diabetes. Patient attitudes toward ED-based diabetes screening support further exploration of this important and currently underutilized opportunity for public health intervention.

A profile of U.S. asthma centers, 2006.

BACKGROUND: Asthma is a significant public health problem that results in 1.8 million annual emergency department (ED) visits. Many ED visits may be prevented with specialized asthma care. OBJECTIVE: To describe US asthma centers with a long-term goal of exploring their potential role in improving outcomes for ED patients with acute asthma. METHODS: We conducted initial online surveys in 2004. One survey identified asthma centers and their directors through reports by emergency medicine researchers and fellowship directors (allergy/immunology, pulmonary, and critical care) at US hospitals. A second survey asked asthma center directors to describe their asthma center. Follow-up surveys were conducted 2 years later in 2006. RESULTS: Eighty-seven (49%) of the 177 hospitals surveyed have asthma clinics. Although spirometry was available on the day of the visit at all asthma centers surveyed in 2006, only 21% (95% confidence interval, 11 %-34%) of sites reported that at least 90% of visits per week included a spirometry test. Only one quarter (26%; 95% confidence interval, 15%-40%) of asthma centers reported that at least 90% of patients undergo a skin or blood test for environmental allergens during 1 of their visits. Half of center directors (53%) were unsure of the approximate number of annual ED visits for acute asthma at their hospital. No significant measured changes were noted in asthma centers between 2004 and 2006. CONCLUSIONS: Asthma centers are heterogenous, with different services available. Although challenges remain, collaboration between EDs and asthma centers may contribute to improved asthma outcomes and merits further study.