Doug Brunk

Researchers have discovered that a common genetic variant of the MET receptor tyrosine kinase on chromosome 7q31 is associated with a 2.27-fold risk of having autism.

This new finding corroborates other works in autism which “indicate altered organization of both the cerebral cortex and the cerebellum, both of which are disrupted in mice with decreased MET signaling activity,” wrote the investigators, who were led by Daniel B. Campbell, Ph.D., of the department of pharmacology at Vanderbilt University in Nashville, Tenn.

“There is co-occurrence of autism with a number of neurological and cognitive disorders, including epilepsy, atypical sleep patterns, and mental retardation. Together with well known dysfunction of cortical information processing, the role of MET signaling in interneuron development is relevant as a central component of the hypothesized GABAergic pathophysiological changes in autism,” Dr. Campbell and his associates said.

The MET gene, which is known for its role in cancer metastasis, is also involved in the regulation of the immune system and in gastrointestinal repair, the investigators said.

The researchers conducted genetic analysis of 743 families who had at least one child with autism (Proc. Natl. Acad. Sci. U.S.A. 2006 Oct. 19 [doi:10.1073/pnas.0605296103]). They found that people with two copies of the MET gene variant were 2.27 times more likely to have autism as were people in the general population.

The risk of autism among study participants who had only one copy of the genetic variant was also high: a relative risk of 1.67 compared with the general population.

In a statement about the study, the researchers noted that the MET gene variant is common, seen in an estimated 47% of the population. However, in the study, Dr. Campbell and his associates emphasized that having the variant is not a stand-alone marker for a diagnosis of autism.

“We hypothesize that the [variant] can, together with other vulnerability genes and epigenetic and environmental factors, precipitate the onset of autism,” they said.

The study was supported in part by a grant from the National Institute of Mental Health and National Institute of Child Health and Human Development.

Researchers have discovered that a common genetic variant of the MET receptor tyrosine kinase on chromosome 7q31 is associated with a 2.27-fold risk of having autism.

This new finding corroborates other works in autism which “indicate altered organization of both the cerebral cortex and the cerebellum, both of which are disrupted in mice with decreased MET signaling activity,” wrote the investigators, who were led by Daniel B. Campbell, Ph.D., of the department of pharmacology at Vanderbilt University in Nashville, Tenn.

“There is co-occurrence of autism with a number of neurological and cognitive disorders, including epilepsy, atypical sleep patterns, and mental retardation. Together with well known dysfunction of cortical information processing, the role of MET signaling in interneuron development is relevant as a central component of the hypothesized GABAergic pathophysiological changes in autism,” Dr. Campbell and his associates said.

The MET gene, which is known for its role in cancer metastasis, is also involved in the regulation of the immune system and in gastrointestinal repair, the investigators said.

The researchers conducted genetic analysis of 743 families who had at least one child with autism (Proc. Natl. Acad. Sci. U.S.A. 2006 Oct. 19 [doi:10.1073/pnas.0605296103]). They found that people with two copies of the MET gene variant were 2.27 times more likely to have autism as were people in the general population.

The risk of autism among study participants who had only one copy of the genetic variant was also high: a relative risk of 1.67 compared with the general population.

In a statement about the study, the researchers noted that the MET gene variant is common, seen in an estimated 47% of the population. However, in the study, Dr. Campbell and his associates emphasized that having the variant is not a stand-alone marker for a diagnosis of autism.

“We hypothesize that the [variant] can, together with other vulnerability genes and epigenetic and environmental factors, precipitate the onset of autism,” they said.

The study was supported in part by a grant from the National Institute of Mental Health and National Institute of Child Health and Human Development.

Researchers have discovered that a common genetic variant of the MET receptor tyrosine kinase on chromosome 7q31 is associated with a 2.27-fold risk of having autism.

This new finding corroborates other works in autism which “indicate altered organization of both the cerebral cortex and the cerebellum, both of which are disrupted in mice with decreased MET signaling activity,” wrote the investigators, who were led by Daniel B. Campbell, Ph.D., of the department of pharmacology at Vanderbilt University in Nashville, Tenn.

“There is co-occurrence of autism with a number of neurological and cognitive disorders, including epilepsy, atypical sleep patterns, and mental retardation. Together with well known dysfunction of cortical information processing, the role of MET signaling in interneuron development is relevant as a central component of the hypothesized GABAergic pathophysiological changes in autism,” Dr. Campbell and his associates said.

The MET gene, which is known for its role in cancer metastasis, is also involved in the regulation of the immune system and in gastrointestinal repair, the investigators said.

The researchers conducted genetic analysis of 743 families who had at least one child with autism (Proc. Natl. Acad. Sci. U.S.A. 2006 Oct. 19 [doi:10.1073/pnas.0605296103]). They found that people with two copies of the MET gene variant were 2.27 times more likely to have autism as were people in the general population.

The risk of autism among study participants who had only one copy of the genetic variant was also high: a relative risk of 1.67 compared with the general population.

In a statement about the study, the researchers noted that the MET gene variant is common, seen in an estimated 47% of the population. However, in the study, Dr. Campbell and his associates emphasized that having the variant is not a stand-alone marker for a diagnosis of autism.

“We hypothesize that the [variant] can, together with other vulnerability genes and epigenetic and environmental factors, precipitate the onset of autism,” they said.

The study was supported in part by a grant from the National Institute of Mental Health and National Institute of Child Health and Human Development.

SAN DIEGO – More than two-thirds of children and adolescents with major depressive disorder who were treated with fluoxetine were in remission by week 12 of treatment, yet almost half of remitters had at least one residual symptom by week 12.

The findings are important because “knowing how early clinicians may expect response or remission in their patients is clinically valuable,” Dr. Rongrong Tao said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

“It may improve [drug] adherence. Knowing the time course of depressive symptom improvement may be helpful in guiding” treatment decisions, Dr. Tao said.

In an open-label study funded by the National Institute of Mental Health, Dr. Tao and her associates in the department of psychiatry at the University of Texas Southwestern Medical Center at Dallas enrolled 168 outpatients aged 7–18 years who had a diagnosis of nonpsychotic major depressive disorder.

Patients with a diagnosis of bipolar I or II disorder were excluded from the study, as were those with anorexia nervosa or bulimia and those with a history of alcohol or substance abuse dependence within 6 months of study entry.

Between 1999 and 2005, the patients received 12 weeks of fluoxetine, starting with a dosage of 10 mg/day for week 1 and increased to 20 mg/day for week 2. Nonresponders received a dosage of 40 mg/day at week 6. The average age of the 168 patients was 12 years, 30% had a recurrent major depressive disorder, and their mean Children's Depression Rating Scale-Revised (CDRS-R) score was 57.57. In addition, 40% had attention-deficit hyperactivity disorder, 32% had dysthymia, and 14% had generalized anxiety disorder.

Study visits occurred weekly for the first 4 weeks and biweekly for the remaining 2 months. During study visits, the researchers administered a battery of tests to assess clinical response, including the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL), the CDRS-R, and the Clinical Global Impression scale.

Dr. Tao reported that the rates of remission were 35% by week 4, 48% by week 6, and 66% by week 12. However, 47% of remitters had at least one residual symptom by the end of 12 weeks, most commonly impaired school performance (19%), impaired sleep (12%), irritability (11%), and low self-esteem (9%).

Clinical response also improved in a stepwise fashion, to rates of 68% by week 4, 76% by week 6, and 81% by week 12. Children aged 11 and younger had earlier responses than their older counterparts did, but by week 12, “their response rates were almost identical,” she said.

SAN DIEGO – More than two-thirds of children and adolescents with major depressive disorder who were treated with fluoxetine were in remission by week 12 of treatment, yet almost half of remitters had at least one residual symptom by week 12.

The findings are important because “knowing how early clinicians may expect response or remission in their patients is clinically valuable,” Dr. Rongrong Tao said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

“It may improve [drug] adherence. Knowing the time course of depressive symptom improvement may be helpful in guiding” treatment decisions, Dr. Tao said.

In an open-label study funded by the National Institute of Mental Health, Dr. Tao and her associates in the department of psychiatry at the University of Texas Southwestern Medical Center at Dallas enrolled 168 outpatients aged 7–18 years who had a diagnosis of nonpsychotic major depressive disorder.

Patients with a diagnosis of bipolar I or II disorder were excluded from the study, as were those with anorexia nervosa or bulimia and those with a history of alcohol or substance abuse dependence within 6 months of study entry.

Between 1999 and 2005, the patients received 12 weeks of fluoxetine, starting with a dosage of 10 mg/day for week 1 and increased to 20 mg/day for week 2. Nonresponders received a dosage of 40 mg/day at week 6. The average age of the 168 patients was 12 years, 30% had a recurrent major depressive disorder, and their mean Children's Depression Rating Scale-Revised (CDRS-R) score was 57.57. In addition, 40% had attention-deficit hyperactivity disorder, 32% had dysthymia, and 14% had generalized anxiety disorder.

Study visits occurred weekly for the first 4 weeks and biweekly for the remaining 2 months. During study visits, the researchers administered a battery of tests to assess clinical response, including the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL), the CDRS-R, and the Clinical Global Impression scale.

Dr. Tao reported that the rates of remission were 35% by week 4, 48% by week 6, and 66% by week 12. However, 47% of remitters had at least one residual symptom by the end of 12 weeks, most commonly impaired school performance (19%), impaired sleep (12%), irritability (11%), and low self-esteem (9%).

Clinical response also improved in a stepwise fashion, to rates of 68% by week 4, 76% by week 6, and 81% by week 12. Children aged 11 and younger had earlier responses than their older counterparts did, but by week 12, “their response rates were almost identical,” she said.

SAN DIEGO – More than two-thirds of children and adolescents with major depressive disorder who were treated with fluoxetine were in remission by week 12 of treatment, yet almost half of remitters had at least one residual symptom by week 12.

The findings are important because “knowing how early clinicians may expect response or remission in their patients is clinically valuable,” Dr. Rongrong Tao said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

“It may improve [drug] adherence. Knowing the time course of depressive symptom improvement may be helpful in guiding” treatment decisions, Dr. Tao said.

In an open-label study funded by the National Institute of Mental Health, Dr. Tao and her associates in the department of psychiatry at the University of Texas Southwestern Medical Center at Dallas enrolled 168 outpatients aged 7–18 years who had a diagnosis of nonpsychotic major depressive disorder.

Patients with a diagnosis of bipolar I or II disorder were excluded from the study, as were those with anorexia nervosa or bulimia and those with a history of alcohol or substance abuse dependence within 6 months of study entry.

Between 1999 and 2005, the patients received 12 weeks of fluoxetine, starting with a dosage of 10 mg/day for week 1 and increased to 20 mg/day for week 2. Nonresponders received a dosage of 40 mg/day at week 6. The average age of the 168 patients was 12 years, 30% had a recurrent major depressive disorder, and their mean Children's Depression Rating Scale-Revised (CDRS-R) score was 57.57. In addition, 40% had attention-deficit hyperactivity disorder, 32% had dysthymia, and 14% had generalized anxiety disorder.

Study visits occurred weekly for the first 4 weeks and biweekly for the remaining 2 months. During study visits, the researchers administered a battery of tests to assess clinical response, including the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL), the CDRS-R, and the Clinical Global Impression scale.

Dr. Tao reported that the rates of remission were 35% by week 4, 48% by week 6, and 66% by week 12. However, 47% of remitters had at least one residual symptom by the end of 12 weeks, most commonly impaired school performance (19%), impaired sleep (12%), irritability (11%), and low self-esteem (9%).

Clinical response also improved in a stepwise fashion, to rates of 68% by week 4, 76% by week 6, and 81% by week 12. Children aged 11 and younger had earlier responses than their older counterparts did, but by week 12, “their response rates were almost identical,” she said.

SAN DIEGO – Children of parents who lost their jobs in the past 3–5 months were more likely to develop psychopathology if they reported three or more moderate to severely stressful life events in the past year than children who reported fewer such events, Dr. Karen L. Weihs reported in an interview during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dr. Weihs of the department of psychiatry at the University of Arizona, Tucson, said in an interview that she and her colleagues found a higher impairment threshold among children than had been previously reported. “When kids had one or two severe [life] events, they didn't seem to have any higher psychopathology … than kids who had none.

“It was only when they had three severe events that their psychopathology risk went way up,” she said. “That's new, because when you study adults, the general finding has been one severe event greatly elevates the risk of psychopathology. There's some resilience factor that kids seem to have.”

In an effort to test whether stressful life events in the past year predicted the mental health of 9− to 13-year-old children 3–5 months after a parent's job loss, the researchers studied 191 mother-child pairs in one- and two-parent families in nine Maryland counties. Adults had to be unemployed in the prior 8 weeks.

The researchers conducted in-home visits with mothers and their children, where they administered an instrument called the Contextual Assessment of Stressful Events in Childhood, the Child Behavior Checklist (CBCL), the Columbia Impairment Scale, the Reynolds Child Depression Scale, and the Manifest Anxiety Scale. (The Contextual Assessment is not published but is available free of charge from the university's psychiatry department.)

“This is a stressed sample,” Dr. Weihs said. “The most severe events were in the work category: family finances causing losses of some sort, having to move, having to go without a vacation–serious kinds of things.”

Dr. Wiehs and her associates found that more externalizing and impairment, as measured by the CBCL, could be predicted among those mothers alone, children alone, and mothers and children together who reported three or more moderately to severely stressful life events than among those who reported fewer events.

However, mothers and children who reported three or more moderately to severely stressful life events differed in their reporting of internalizing symptoms. Mothers were more likely than their children to report internalizing symptoms, as measured by the CBCL, while children were more likely than their mothers to report symptoms of depression and anxiety, as measured by the other scales used in the interviews.

One possible explanation Dr. Weihs saw for the discrepancy is the salience of the mothers' reporting.

“A parent might remember something like the kid flunking a major exam or having to do extra schooling in the summer, whereas the kid doesn't want to think about that and might not even tell [the parent] about it,” she said.

She added that one implication of the study is that when you're interviewing children clinically, one should remember that the child might omit some important information from the parent, and vice versa, Dr. Weihs advised.

Information from both the parents and the child can be predictive of how much psychopathology the child is going to have, she said. “It also speaks strongly for making sure we talk to kids and parents, not just one or the other.”

SAN DIEGO – Children of parents who lost their jobs in the past 3–5 months were more likely to develop psychopathology if they reported three or more moderate to severely stressful life events in the past year than children who reported fewer such events, Dr. Karen L. Weihs reported in an interview during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dr. Weihs of the department of psychiatry at the University of Arizona, Tucson, said in an interview that she and her colleagues found a higher impairment threshold among children than had been previously reported. “When kids had one or two severe [life] events, they didn't seem to have any higher psychopathology … than kids who had none.

“It was only when they had three severe events that their psychopathology risk went way up,” she said. “That's new, because when you study adults, the general finding has been one severe event greatly elevates the risk of psychopathology. There's some resilience factor that kids seem to have.”

In an effort to test whether stressful life events in the past year predicted the mental health of 9− to 13-year-old children 3–5 months after a parent's job loss, the researchers studied 191 mother-child pairs in one- and two-parent families in nine Maryland counties. Adults had to be unemployed in the prior 8 weeks.

The researchers conducted in-home visits with mothers and their children, where they administered an instrument called the Contextual Assessment of Stressful Events in Childhood, the Child Behavior Checklist (CBCL), the Columbia Impairment Scale, the Reynolds Child Depression Scale, and the Manifest Anxiety Scale. (The Contextual Assessment is not published but is available free of charge from the university's psychiatry department.)

“This is a stressed sample,” Dr. Weihs said. “The most severe events were in the work category: family finances causing losses of some sort, having to move, having to go without a vacation–serious kinds of things.”

Dr. Wiehs and her associates found that more externalizing and impairment, as measured by the CBCL, could be predicted among those mothers alone, children alone, and mothers and children together who reported three or more moderately to severely stressful life events than among those who reported fewer events.

However, mothers and children who reported three or more moderately to severely stressful life events differed in their reporting of internalizing symptoms. Mothers were more likely than their children to report internalizing symptoms, as measured by the CBCL, while children were more likely than their mothers to report symptoms of depression and anxiety, as measured by the other scales used in the interviews.

One possible explanation Dr. Weihs saw for the discrepancy is the salience of the mothers' reporting.

“A parent might remember something like the kid flunking a major exam or having to do extra schooling in the summer, whereas the kid doesn't want to think about that and might not even tell [the parent] about it,” she said.

She added that one implication of the study is that when you're interviewing children clinically, one should remember that the child might omit some important information from the parent, and vice versa, Dr. Weihs advised.

Information from both the parents and the child can be predictive of how much psychopathology the child is going to have, she said. “It also speaks strongly for making sure we talk to kids and parents, not just one or the other.”

SAN DIEGO – Children of parents who lost their jobs in the past 3–5 months were more likely to develop psychopathology if they reported three or more moderate to severely stressful life events in the past year than children who reported fewer such events, Dr. Karen L. Weihs reported in an interview during a poster session at the annual meeting of the American Academy of Child and Adolescent Psychiatry.

Dr. Weihs of the department of psychiatry at the University of Arizona, Tucson, said in an interview that she and her colleagues found a higher impairment threshold among children than had been previously reported. “When kids had one or two severe [life] events, they didn't seem to have any higher psychopathology … than kids who had none.

“It was only when they had three severe events that their psychopathology risk went way up,” she said. “That's new, because when you study adults, the general finding has been one severe event greatly elevates the risk of psychopathology. There's some resilience factor that kids seem to have.”

In an effort to test whether stressful life events in the past year predicted the mental health of 9− to 13-year-old children 3–5 months after a parent's job loss, the researchers studied 191 mother-child pairs in one- and two-parent families in nine Maryland counties. Adults had to be unemployed in the prior 8 weeks.

The researchers conducted in-home visits with mothers and their children, where they administered an instrument called the Contextual Assessment of Stressful Events in Childhood, the Child Behavior Checklist (CBCL), the Columbia Impairment Scale, the Reynolds Child Depression Scale, and the Manifest Anxiety Scale. (The Contextual Assessment is not published but is available free of charge from the university's psychiatry department.)

“This is a stressed sample,” Dr. Weihs said. “The most severe events were in the work category: family finances causing losses of some sort, having to move, having to go without a vacation–serious kinds of things.”

Dr. Wiehs and her associates found that more externalizing and impairment, as measured by the CBCL, could be predicted among those mothers alone, children alone, and mothers and children together who reported three or more moderately to severely stressful life events than among those who reported fewer events.

However, mothers and children who reported three or more moderately to severely stressful life events differed in their reporting of internalizing symptoms. Mothers were more likely than their children to report internalizing symptoms, as measured by the CBCL, while children were more likely than their mothers to report symptoms of depression and anxiety, as measured by the other scales used in the interviews.

One possible explanation Dr. Weihs saw for the discrepancy is the salience of the mothers' reporting.

“A parent might remember something like the kid flunking a major exam or having to do extra schooling in the summer, whereas the kid doesn't want to think about that and might not even tell [the parent] about it,” she said.

She added that one implication of the study is that when you're interviewing children clinically, one should remember that the child might omit some important information from the parent, and vice versa, Dr. Weihs advised.

Information from both the parents and the child can be predictive of how much psychopathology the child is going to have, she said. “It also speaks strongly for making sure we talk to kids and parents, not just one or the other.”

SAN FRANCISCO—An empiric antibiotic treatment algorithm for community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections improved clinical outcomes, according to the results of a small study.

“We recommend treating people with skin and soft tissue infections with Bactrim and Keflex or clindamycin in addition to early incision and drainage,” Dr. Erin A. Chuck said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

She and her colleagues at Alameda County Medical Center in Oakland, Calif., reviewed the charts of 50 consecutive patients treated in the ED for laboratory-confirmed community-acquired methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections and were sent home the same day between April 2005 and January 2006. They categorized treatment as either conforming to or not conforming to the algorithm, which classified infections as follows:

▸ Type 1: Uncomplicated cellulitis or impetigo. The recommended treatment was cephalexin (Keflex) plus trimethoprim-sulfamethoxazole (TMP/SMX).

▸ Type 2: Uncomplicated abscesses. The recommended treatment was surgery, but if antibiotics were used the researchers recommended doxycycline or TMP/SMX alone.

▸ Type 3: Complicated abscesses, such as those with surrounding cellulitis, infections in immunocompromised hosts, or infected wounds. The recommended treatment was to consider surgery, to administer oral Keflex plus TMP/SMX or clindamycin alone, or to administer intravenous clindamycin plus vancomycin or Zosyn (piperacillin sodium and tazobactam sodium) plus vancomycin.

Of the 50 patients, 37 had abscesses that were drained at the first visit, said Dr. Chuck, who conducted the study during her residency at the medical center.

Of the 29 patients treated according to the algorithm, only 1 (3%) was considered a clinical failure, vs. 13 (62%) who were not treated according to the algorithm.

Of the 36 patients treated with antibiotics that were active in vitro against their MRSA isolate, 4 (11%) were considered clinical failures. Of the 9 patients treated with antibiotics that were inactive against their cultured MRSA, 7 (78%) were considered clinical failures. No patient treated according to the algorithm was subsequently hospitalized, vs. two not treated according to the algorithm, she said at the meeting, sponsored by the American Society for Microbiology. Dr. Chuck is now a hospitalist at John Muir Hospital in Walnut Creek, Calif.

SAN FRANCISCO—An empiric antibiotic treatment algorithm for community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections improved clinical outcomes, according to the results of a small study.

“We recommend treating people with skin and soft tissue infections with Bactrim and Keflex or clindamycin in addition to early incision and drainage,” Dr. Erin A. Chuck said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

She and her colleagues at Alameda County Medical Center in Oakland, Calif., reviewed the charts of 50 consecutive patients treated in the ED for laboratory-confirmed community-acquired methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections and were sent home the same day between April 2005 and January 2006. They categorized treatment as either conforming to or not conforming to the algorithm, which classified infections as follows:

▸ Type 1: Uncomplicated cellulitis or impetigo. The recommended treatment was cephalexin (Keflex) plus trimethoprim-sulfamethoxazole (TMP/SMX).

▸ Type 2: Uncomplicated abscesses. The recommended treatment was surgery, but if antibiotics were used the researchers recommended doxycycline or TMP/SMX alone.

▸ Type 3: Complicated abscesses, such as those with surrounding cellulitis, infections in immunocompromised hosts, or infected wounds. The recommended treatment was to consider surgery, to administer oral Keflex plus TMP/SMX or clindamycin alone, or to administer intravenous clindamycin plus vancomycin or Zosyn (piperacillin sodium and tazobactam sodium) plus vancomycin.

Of the 50 patients, 37 had abscesses that were drained at the first visit, said Dr. Chuck, who conducted the study during her residency at the medical center.

Of the 29 patients treated according to the algorithm, only 1 (3%) was considered a clinical failure, vs. 13 (62%) who were not treated according to the algorithm.

Of the 36 patients treated with antibiotics that were active in vitro against their MRSA isolate, 4 (11%) were considered clinical failures. Of the 9 patients treated with antibiotics that were inactive against their cultured MRSA, 7 (78%) were considered clinical failures. No patient treated according to the algorithm was subsequently hospitalized, vs. two not treated according to the algorithm, she said at the meeting, sponsored by the American Society for Microbiology. Dr. Chuck is now a hospitalist at John Muir Hospital in Walnut Creek, Calif.

SAN FRANCISCO—An empiric antibiotic treatment algorithm for community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections improved clinical outcomes, according to the results of a small study.

“We recommend treating people with skin and soft tissue infections with Bactrim and Keflex or clindamycin in addition to early incision and drainage,” Dr. Erin A. Chuck said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

She and her colleagues at Alameda County Medical Center in Oakland, Calif., reviewed the charts of 50 consecutive patients treated in the ED for laboratory-confirmed community-acquired methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections and were sent home the same day between April 2005 and January 2006. They categorized treatment as either conforming to or not conforming to the algorithm, which classified infections as follows:

▸ Type 1: Uncomplicated cellulitis or impetigo. The recommended treatment was cephalexin (Keflex) plus trimethoprim-sulfamethoxazole (TMP/SMX).

▸ Type 2: Uncomplicated abscesses. The recommended treatment was surgery, but if antibiotics were used the researchers recommended doxycycline or TMP/SMX alone.

▸ Type 3: Complicated abscesses, such as those with surrounding cellulitis, infections in immunocompromised hosts, or infected wounds. The recommended treatment was to consider surgery, to administer oral Keflex plus TMP/SMX or clindamycin alone, or to administer intravenous clindamycin plus vancomycin or Zosyn (piperacillin sodium and tazobactam sodium) plus vancomycin.

Of the 50 patients, 37 had abscesses that were drained at the first visit, said Dr. Chuck, who conducted the study during her residency at the medical center.

Of the 29 patients treated according to the algorithm, only 1 (3%) was considered a clinical failure, vs. 13 (62%) who were not treated according to the algorithm.

Of the 36 patients treated with antibiotics that were active in vitro against their MRSA isolate, 4 (11%) were considered clinical failures. Of the 9 patients treated with antibiotics that were inactive against their cultured MRSA, 7 (78%) were considered clinical failures. No patient treated according to the algorithm was subsequently hospitalized, vs. two not treated according to the algorithm, she said at the meeting, sponsored by the American Society for Microbiology. Dr. Chuck is now a hospitalist at John Muir Hospital in Walnut Creek, Calif.

SAN FRANCISCO—Independent clinical risk factors for vancomycin failure in patients with methicillin-resistant Staphylococcus aureus infection were infection of the lung or pleura and, to a lesser extent, infection of the bone, results from a small case-control study showed.

“Vancomycin doesn't penetrate the pleura and the lungs as well as newer generations of drugs for MRSA,” Dr. Roger Mar-Tang said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “A consideration may be to use a different agent if you suspect MRSA infection in the lung or pleura.”

He and his associates at the University of California, Davis Medical Center in Sacramento studied 55 cases of MRSA infection that were not successfully treated with vancomycin between July 1, 2003, and June 30, 2005; 75 MRSA patients treated successfully in that period served as controls.

Vancomycin failure was defined as patients who received at least 5 days of therapy and met one of three criteria: They had repeat positive MRSA cultures, showed continued or worsening signs or symptoms of infection, or died after 5 days of therapy for the MRSA infection.

Univariate analysis showed that the clinical risk factors for vancomycin failure were renal insufficiency or failure (affecting 44% of cases vs. 27% of controls), history of myocardial infarction (24% vs. 11% among controls), MRSA infection of the lung or pleura (53% vs. 19% among controls), and MRSA infection of the bone (9% vs. 1% among controls). Multivariate analysis showed that the only independent clinical risk factors for vancomycin failure were MRSA infection of the lung or pleura (odds ratio of 19.5) and MRSA infection of the bone (odds ratio of 8.22).

Dr. Mar-Tang conducted the study during his internal medicine residency at the University of California, Davis Medical Center. The conference was sponsored by the American Society for Microbiology.

SAN FRANCISCO—Independent clinical risk factors for vancomycin failure in patients with methicillin-resistant Staphylococcus aureus infection were infection of the lung or pleura and, to a lesser extent, infection of the bone, results from a small case-control study showed.

“Vancomycin doesn't penetrate the pleura and the lungs as well as newer generations of drugs for MRSA,” Dr. Roger Mar-Tang said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “A consideration may be to use a different agent if you suspect MRSA infection in the lung or pleura.”

He and his associates at the University of California, Davis Medical Center in Sacramento studied 55 cases of MRSA infection that were not successfully treated with vancomycin between July 1, 2003, and June 30, 2005; 75 MRSA patients treated successfully in that period served as controls.

Vancomycin failure was defined as patients who received at least 5 days of therapy and met one of three criteria: They had repeat positive MRSA cultures, showed continued or worsening signs or symptoms of infection, or died after 5 days of therapy for the MRSA infection.

Univariate analysis showed that the clinical risk factors for vancomycin failure were renal insufficiency or failure (affecting 44% of cases vs. 27% of controls), history of myocardial infarction (24% vs. 11% among controls), MRSA infection of the lung or pleura (53% vs. 19% among controls), and MRSA infection of the bone (9% vs. 1% among controls). Multivariate analysis showed that the only independent clinical risk factors for vancomycin failure were MRSA infection of the lung or pleura (odds ratio of 19.5) and MRSA infection of the bone (odds ratio of 8.22).

Dr. Mar-Tang conducted the study during his internal medicine residency at the University of California, Davis Medical Center. The conference was sponsored by the American Society for Microbiology.

SAN FRANCISCO—Independent clinical risk factors for vancomycin failure in patients with methicillin-resistant Staphylococcus aureus infection were infection of the lung or pleura and, to a lesser extent, infection of the bone, results from a small case-control study showed.

“Vancomycin doesn't penetrate the pleura and the lungs as well as newer generations of drugs for MRSA,” Dr. Roger Mar-Tang said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “A consideration may be to use a different agent if you suspect MRSA infection in the lung or pleura.”

He and his associates at the University of California, Davis Medical Center in Sacramento studied 55 cases of MRSA infection that were not successfully treated with vancomycin between July 1, 2003, and June 30, 2005; 75 MRSA patients treated successfully in that period served as controls.

Vancomycin failure was defined as patients who received at least 5 days of therapy and met one of three criteria: They had repeat positive MRSA cultures, showed continued or worsening signs or symptoms of infection, or died after 5 days of therapy for the MRSA infection.

Univariate analysis showed that the clinical risk factors for vancomycin failure were renal insufficiency or failure (affecting 44% of cases vs. 27% of controls), history of myocardial infarction (24% vs. 11% among controls), MRSA infection of the lung or pleura (53% vs. 19% among controls), and MRSA infection of the bone (9% vs. 1% among controls). Multivariate analysis showed that the only independent clinical risk factors for vancomycin failure were MRSA infection of the lung or pleura (odds ratio of 19.5) and MRSA infection of the bone (odds ratio of 8.22).

Dr. Mar-Tang conducted the study during his internal medicine residency at the University of California, Davis Medical Center. The conference was sponsored by the American Society for Microbiology.

CARLSBAD, CALIF.—Some acne patients may respond to various light-based treatments, but most of the time the improvement is modest and short-lived, Dr. E. Victor Ross Jr. said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

Most light-based therapies for acne "don't work as well as they should," said Dr. Ross, director of the Scripps Clinic Skin and Cosmetic Center in La Jolla, Calif. "The bar should be pretty high. If we're having patients sit under these lights and have these therapies, I think that means long remission periods with one treatment, not five treatments every 2 or 3 weeks, and evidence that there's some robust compromise of the sebaceous gland."

Most patients who seek light-based treatments for their acne have been on isotretinoin in the past yet are unwilling to be on systemic retinoids again. "They don't have severe acne, but they have cyclical moderate acne, and they're tired and frustrated with the typical" therapies, Dr. Ross said.

Light therapies don't work well for acne because a photochemical effect should prevail over any photothermal effect to excite endogenous porphyrins produced by Propionibacterium acnes. In addition, the only studies to show microscopic damage to the sebaceous gland have been those with long incubation times, continuous-wave light sources, and red light only. This regimen caused epidermal damage in every case, he noted.

"It's unlikely that one will achieve long-term and profound sebaceous gland compromise with short aminolevulinic acid times, either with pulsed light sources or with continuous-wave light sources," he said. "Right now we have to be honest with ourselves and say the prescription pad is still pretty darned good. … I've tried these [light] therapies, but I'm not ready to say these are a home run or even a triple or double right now."

He added that many patients who undergo light treatment for their acne fail what he calls the "come back" test. "They don't come back. If they don't come back, [we assume] they're probably better, but I suspect that most of them are not better, they're worse," he said.

Dr. Ross disclosed that he has research relationships with Palomar, Cutera, and Laserscope.

CARLSBAD, CALIF.—Some acne patients may respond to various light-based treatments, but most of the time the improvement is modest and short-lived, Dr. E. Victor Ross Jr. said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

Most light-based therapies for acne "don't work as well as they should," said Dr. Ross, director of the Scripps Clinic Skin and Cosmetic Center in La Jolla, Calif. "The bar should be pretty high. If we're having patients sit under these lights and have these therapies, I think that means long remission periods with one treatment, not five treatments every 2 or 3 weeks, and evidence that there's some robust compromise of the sebaceous gland."

Most patients who seek light-based treatments for their acne have been on isotretinoin in the past yet are unwilling to be on systemic retinoids again. "They don't have severe acne, but they have cyclical moderate acne, and they're tired and frustrated with the typical" therapies, Dr. Ross said.

Light therapies don't work well for acne because a photochemical effect should prevail over any photothermal effect to excite endogenous porphyrins produced by Propionibacterium acnes. In addition, the only studies to show microscopic damage to the sebaceous gland have been those with long incubation times, continuous-wave light sources, and red light only. This regimen caused epidermal damage in every case, he noted.

"It's unlikely that one will achieve long-term and profound sebaceous gland compromise with short aminolevulinic acid times, either with pulsed light sources or with continuous-wave light sources," he said. "Right now we have to be honest with ourselves and say the prescription pad is still pretty darned good. … I've tried these [light] therapies, but I'm not ready to say these are a home run or even a triple or double right now."

He added that many patients who undergo light treatment for their acne fail what he calls the "come back" test. "They don't come back. If they don't come back, [we assume] they're probably better, but I suspect that most of them are not better, they're worse," he said.

Dr. Ross disclosed that he has research relationships with Palomar, Cutera, and Laserscope.

CARLSBAD, CALIF.—Some acne patients may respond to various light-based treatments, but most of the time the improvement is modest and short-lived, Dr. E. Victor Ross Jr. said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

Most light-based therapies for acne "don't work as well as they should," said Dr. Ross, director of the Scripps Clinic Skin and Cosmetic Center in La Jolla, Calif. "The bar should be pretty high. If we're having patients sit under these lights and have these therapies, I think that means long remission periods with one treatment, not five treatments every 2 or 3 weeks, and evidence that there's some robust compromise of the sebaceous gland."

Most patients who seek light-based treatments for their acne have been on isotretinoin in the past yet are unwilling to be on systemic retinoids again. "They don't have severe acne, but they have cyclical moderate acne, and they're tired and frustrated with the typical" therapies, Dr. Ross said.

Light therapies don't work well for acne because a photochemical effect should prevail over any photothermal effect to excite endogenous porphyrins produced by Propionibacterium acnes. In addition, the only studies to show microscopic damage to the sebaceous gland have been those with long incubation times, continuous-wave light sources, and red light only. This regimen caused epidermal damage in every case, he noted.

"It's unlikely that one will achieve long-term and profound sebaceous gland compromise with short aminolevulinic acid times, either with pulsed light sources or with continuous-wave light sources," he said. "Right now we have to be honest with ourselves and say the prescription pad is still pretty darned good. … I've tried these [light] therapies, but I'm not ready to say these are a home run or even a triple or double right now."

He added that many patients who undergo light treatment for their acne fail what he calls the "come back" test. "They don't come back. If they don't come back, [we assume] they're probably better, but I suspect that most of them are not better, they're worse," he said.

Dr. Ross disclosed that he has research relationships with Palomar, Cutera, and Laserscope.

CARLSBAD, CALIF.—At a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians, Dr. E. Victor Ross Jr., shared what he looks for in a good intense pulsed light device.

First, he looks for variability in spectral shapes. This allows tailoring and fine-tuning of applications to control the clinical outcome, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Center in San Diego.

The ability to predictably treat vascular lesions while preserving epidermal pigmentation includes the ability to treat through a tan. "I always hear people from the northeast say, 'We don't treat tanned patients.' You have to be cautious, but you can do it," he said. With tanned patients you need to use "all the weapons [you have], which means external cooling and internal cooling, particularly between the vascular lesions."

Efficient cooling is also important. "It's not about cooling the skin," he said. "It's about keeping the hand piece cool."

IPL devices should also support some laser platforms, such as the erbium:YAG, the neodymium:YAG, or the erbium glass laser, he said, adding that a reliable external calibration system that interrogates the entire system from the power supply to the quartz or sapphire end piece is important. He also recommended user-selectable pulse durations that allow for the proper balance of fluence, wavelength, and cooling.

Dr. Ross also mentioned the importance of reproducibility in outcomes from machine to machine based on the same panel settings, and long lamp lifetimes with minimal degradation over thousands of pulses.

Rounding out the list of qualities are flexibility in spot size, reasonably fast repetition rates, and ergonomic simplicity.

Undesirable IPL features, he said, include no integrated cooling, small spot size, no capability for laser upgrades, and subpar calibration algorithms.

Candidates for his "Miss IPL" contest include the StarLux, the Luminus One, the Omnilight and the Xeo. "But there are many [others] I just haven't gotten in contact with," said Dr. Ross, who disclosed that he has research relationships with Palomar, Cutera, and Laserscope. "These are the ones I like and know."

He concluded that the best IPL "is the one you feel most comfortable with, the one you use so much that your fingers intuitively move to the right locations on the instrument panel, and the one you feel comfortable teaching people about."

In a panel discussion, Dr. Christopher B. Zachary echoed that notion. "It's all about getting a device that you trust, that you know, that you are capable of using day in and day out," said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine. "There's a huge difference between using the old intense pulsed light devices and the new ones. The new ones are much more efficient."

CARLSBAD, CALIF.—At a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians, Dr. E. Victor Ross Jr., shared what he looks for in a good intense pulsed light device.

First, he looks for variability in spectral shapes. This allows tailoring and fine-tuning of applications to control the clinical outcome, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Center in San Diego.

The ability to predictably treat vascular lesions while preserving epidermal pigmentation includes the ability to treat through a tan. "I always hear people from the northeast say, 'We don't treat tanned patients.' You have to be cautious, but you can do it," he said. With tanned patients you need to use "all the weapons [you have], which means external cooling and internal cooling, particularly between the vascular lesions."

Efficient cooling is also important. "It's not about cooling the skin," he said. "It's about keeping the hand piece cool."

IPL devices should also support some laser platforms, such as the erbium:YAG, the neodymium:YAG, or the erbium glass laser, he said, adding that a reliable external calibration system that interrogates the entire system from the power supply to the quartz or sapphire end piece is important. He also recommended user-selectable pulse durations that allow for the proper balance of fluence, wavelength, and cooling.

Dr. Ross also mentioned the importance of reproducibility in outcomes from machine to machine based on the same panel settings, and long lamp lifetimes with minimal degradation over thousands of pulses.

Rounding out the list of qualities are flexibility in spot size, reasonably fast repetition rates, and ergonomic simplicity.

Undesirable IPL features, he said, include no integrated cooling, small spot size, no capability for laser upgrades, and subpar calibration algorithms.

Candidates for his "Miss IPL" contest include the StarLux, the Luminus One, the Omnilight and the Xeo. "But there are many [others] I just haven't gotten in contact with," said Dr. Ross, who disclosed that he has research relationships with Palomar, Cutera, and Laserscope. "These are the ones I like and know."

He concluded that the best IPL "is the one you feel most comfortable with, the one you use so much that your fingers intuitively move to the right locations on the instrument panel, and the one you feel comfortable teaching people about."

In a panel discussion, Dr. Christopher B. Zachary echoed that notion. "It's all about getting a device that you trust, that you know, that you are capable of using day in and day out," said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine. "There's a huge difference between using the old intense pulsed light devices and the new ones. The new ones are much more efficient."

CARLSBAD, CALIF.—At a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians, Dr. E. Victor Ross Jr., shared what he looks for in a good intense pulsed light device.

First, he looks for variability in spectral shapes. This allows tailoring and fine-tuning of applications to control the clinical outcome, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Center in San Diego.

The ability to predictably treat vascular lesions while preserving epidermal pigmentation includes the ability to treat through a tan. "I always hear people from the northeast say, 'We don't treat tanned patients.' You have to be cautious, but you can do it," he said. With tanned patients you need to use "all the weapons [you have], which means external cooling and internal cooling, particularly between the vascular lesions."

Efficient cooling is also important. "It's not about cooling the skin," he said. "It's about keeping the hand piece cool."

IPL devices should also support some laser platforms, such as the erbium:YAG, the neodymium:YAG, or the erbium glass laser, he said, adding that a reliable external calibration system that interrogates the entire system from the power supply to the quartz or sapphire end piece is important. He also recommended user-selectable pulse durations that allow for the proper balance of fluence, wavelength, and cooling.

Dr. Ross also mentioned the importance of reproducibility in outcomes from machine to machine based on the same panel settings, and long lamp lifetimes with minimal degradation over thousands of pulses.

Rounding out the list of qualities are flexibility in spot size, reasonably fast repetition rates, and ergonomic simplicity.

Undesirable IPL features, he said, include no integrated cooling, small spot size, no capability for laser upgrades, and subpar calibration algorithms.

Candidates for his "Miss IPL" contest include the StarLux, the Luminus One, the Omnilight and the Xeo. "But there are many [others] I just haven't gotten in contact with," said Dr. Ross, who disclosed that he has research relationships with Palomar, Cutera, and Laserscope. "These are the ones I like and know."

He concluded that the best IPL "is the one you feel most comfortable with, the one you use so much that your fingers intuitively move to the right locations on the instrument panel, and the one you feel comfortable teaching people about."

In a panel discussion, Dr. Christopher B. Zachary echoed that notion. "It's all about getting a device that you trust, that you know, that you are capable of using day in and day out," said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine. "There's a huge difference between using the old intense pulsed light devices and the new ones. The new ones are much more efficient."

LAS VEGAS — If a newborn girl develops vesicles or pustules over the trunk and extremities, think incontinentia pigmenti, Dr. Moise L. Levy said at meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“With incontinentia pigmenti you'll have a staged eruption, with vesicles or pustules at the time of birth within the first weeks, followed by more warty or verrucous papules,” said Dr. Levy, professor of dermatology and pediatrics at Baylor College of Medicine, Houston.

By the first year of life a swirling gray-brown hyperpigmentation develops. “This is due to incontinence of pigment,” he explained. “Melanin has dropped out of the basal layer of epidermis into the upper dermis.” The condition occurs primarily in females and is marked by staged cutaneous eruptions.

“You should regard it as a potentially neurocutaneous syndrome,” said Dr. Levy, also chief of the dermatology service at Texas Children's Hospital, Houston. “Eosinophilia can be seen during stage 1, which is the vesicular stage.”

The gene for incontinentia pigmenti has been mapped to Xq28. Deletions at this site cause mutations in NF-kB essential modulator (NEMO), which governs a variety of inflammatory and immune responses. These mutations can lead to skin lesions, vascular anomalies, and immune dysfunction.

Dr. Levy noted that 80% of incontinentia pigmenti cases are caused by mutations in NEMO. Management of the skin lesions is generally supportive. Careful ophthalmologic and neurologic follow-up is indicated in some cases.

At the meeting, Dr. Levy also discussed the clinical signs of another skin defect that can affect newborns: aplasia cutis congenita. This condition is marked by focal congenital skin defects that most often appear on the scalp or face. It also can occur along the temporal area, a version known as focal facial dermal hypoplasia.

Aplasia cutis congenita is “rarely on the trunk or extremities, though this can happen anywhere,” he said. “The etiologies are really varied and may include vascular insufficiency, intrauterine infections, and amniotic membranes. On the scalp, this might be due to defects of closure.”

In your work-up, consider these malformation syndromes that may be associated with aplasia cutis congenita: Opitz syndrome, Adams-Oliver syndrome, Trisomy 13–15 syndrome, 4p syndrome, Johanson-Blizzard syndrome, and Xp22 microdeletion.

Some cases of aplasia cutis congenita will have a so-called hair collar sign, which is a ring of dark hair that often surrounds a scalp lesion. The hair collar sign “suggests cranial dysraphism, especially with overlying vascular malformation.”

LAS VEGAS — If a newborn girl develops vesicles or pustules over the trunk and extremities, think incontinentia pigmenti, Dr. Moise L. Levy said at meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“With incontinentia pigmenti you'll have a staged eruption, with vesicles or pustules at the time of birth within the first weeks, followed by more warty or verrucous papules,” said Dr. Levy, professor of dermatology and pediatrics at Baylor College of Medicine, Houston.

By the first year of life a swirling gray-brown hyperpigmentation develops. “This is due to incontinence of pigment,” he explained. “Melanin has dropped out of the basal layer of epidermis into the upper dermis.” The condition occurs primarily in females and is marked by staged cutaneous eruptions.

“You should regard it as a potentially neurocutaneous syndrome,” said Dr. Levy, also chief of the dermatology service at Texas Children's Hospital, Houston. “Eosinophilia can be seen during stage 1, which is the vesicular stage.”

The gene for incontinentia pigmenti has been mapped to Xq28. Deletions at this site cause mutations in NF-kB essential modulator (NEMO), which governs a variety of inflammatory and immune responses. These mutations can lead to skin lesions, vascular anomalies, and immune dysfunction.

Dr. Levy noted that 80% of incontinentia pigmenti cases are caused by mutations in NEMO. Management of the skin lesions is generally supportive. Careful ophthalmologic and neurologic follow-up is indicated in some cases.

At the meeting, Dr. Levy also discussed the clinical signs of another skin defect that can affect newborns: aplasia cutis congenita. This condition is marked by focal congenital skin defects that most often appear on the scalp or face. It also can occur along the temporal area, a version known as focal facial dermal hypoplasia.

Aplasia cutis congenita is “rarely on the trunk or extremities, though this can happen anywhere,” he said. “The etiologies are really varied and may include vascular insufficiency, intrauterine infections, and amniotic membranes. On the scalp, this might be due to defects of closure.”

In your work-up, consider these malformation syndromes that may be associated with aplasia cutis congenita: Opitz syndrome, Adams-Oliver syndrome, Trisomy 13–15 syndrome, 4p syndrome, Johanson-Blizzard syndrome, and Xp22 microdeletion.

Some cases of aplasia cutis congenita will have a so-called hair collar sign, which is a ring of dark hair that often surrounds a scalp lesion. The hair collar sign “suggests cranial dysraphism, especially with overlying vascular malformation.”

LAS VEGAS — If a newborn girl develops vesicles or pustules over the trunk and extremities, think incontinentia pigmenti, Dr. Moise L. Levy said at meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

“With incontinentia pigmenti you'll have a staged eruption, with vesicles or pustules at the time of birth within the first weeks, followed by more warty or verrucous papules,” said Dr. Levy, professor of dermatology and pediatrics at Baylor College of Medicine, Houston.

By the first year of life a swirling gray-brown hyperpigmentation develops. “This is due to incontinence of pigment,” he explained. “Melanin has dropped out of the basal layer of epidermis into the upper dermis.” The condition occurs primarily in females and is marked by staged cutaneous eruptions.

“You should regard it as a potentially neurocutaneous syndrome,” said Dr. Levy, also chief of the dermatology service at Texas Children's Hospital, Houston. “Eosinophilia can be seen during stage 1, which is the vesicular stage.”

The gene for incontinentia pigmenti has been mapped to Xq28. Deletions at this site cause mutations in NF-kB essential modulator (NEMO), which governs a variety of inflammatory and immune responses. These mutations can lead to skin lesions, vascular anomalies, and immune dysfunction.

Dr. Levy noted that 80% of incontinentia pigmenti cases are caused by mutations in NEMO. Management of the skin lesions is generally supportive. Careful ophthalmologic and neurologic follow-up is indicated in some cases.

At the meeting, Dr. Levy also discussed the clinical signs of another skin defect that can affect newborns: aplasia cutis congenita. This condition is marked by focal congenital skin defects that most often appear on the scalp or face. It also can occur along the temporal area, a version known as focal facial dermal hypoplasia.

Aplasia cutis congenita is “rarely on the trunk or extremities, though this can happen anywhere,” he said. “The etiologies are really varied and may include vascular insufficiency, intrauterine infections, and amniotic membranes. On the scalp, this might be due to defects of closure.”

In your work-up, consider these malformation syndromes that may be associated with aplasia cutis congenita: Opitz syndrome, Adams-Oliver syndrome, Trisomy 13–15 syndrome, 4p syndrome, Johanson-Blizzard syndrome, and Xp22 microdeletion.

Some cases of aplasia cutis congenita will have a so-called hair collar sign, which is a ring of dark hair that often surrounds a scalp lesion. The hair collar sign “suggests cranial dysraphism, especially with overlying vascular malformation.”

LAS VEGAS — If a child presents to your office with fever, chills, muscle pain, joint swelling/pain, and a skin rash and has a pet rat, consider rat bite fever, Dr. Jay M. Lieberman advised at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

In the summer of 2002, one of his colleagues at Miller Children's Hospital in Long Beach, Calif., consulted on a 6-year-old boy who was admitted with a 3-day history of fever as high as 103 and petechial and pustular lesions on his feet. He had initially complained of left ankle pain and refusal to walk and then had diffuse pain of the left knee, elbow, and wrist.

The boy's lab tests were normal except for a low blood platelet count (146,000/mcL of blood). Liver function tests also were normal. The family was from Pennsylvania and had been living in southern California for 2 months. The patient had a pet rat that the family had acquired several weeks before the onset of his symptoms.

“This boy liked to kiss his rat,” said Dr. Lieberman, chief of pediatric infectious diseases at the hospital.

The history of the pet rat prompted Dr. Lieberman's colleague to review the medical literature on rat bite fever, and it became apparent that the boy had a classic presentation of the disease. Rat bite fever is caused by Streptobacillus moniliformis, a bacterium that is found in the normal oral flora of rats and can be excreted in rat urine.

Humans can become infected with S. moniliformis after a bite or scratch from the infected rat, from handling it, or by ingesting food or water contaminated with rat excrement.

The incubation period ranges from 2 to 10 days and patients present with a flu-like illness, including an abrupt onset of fever, chills, headache, and myalgia. A rash may develop 2–4 days after the onset of fever.

The rash “is usually maculopapular, predominantly involves the palms and soles, and may evolve into petechia, purpura, and vesicles,” said Dr. Lieberman, who also is a professor of pediatrics at the University of California, Irvine.

Penicillin G is the treatment of choice, and the boy improved rapidly once on the regimen. Untreated, the infection may have a relapsing course for 3 weeks or more with a case fatality rate as high as 10%.

Dr. Lieberman said the case underscores the importance of asking about pets in every febrile patient and considering the possibility of rat bite fever in acutely ill patients with rat exposure.

According to the textbooks, “children inhabiting crowded urban dwellings or rural areas infested with wild rats” are at risk. Half or more of wild rats carry the organism in their nasopharynx, Dr. Lieberman explained.

According to the Centers for Disease Control and Prevention, two people died from rat bite fever in 2003 (MMWR 2005;53:1198–202). One of the victims, a previously healthy 19-year-old woman in Washington, was pronounced dead upon arrival at a hospital emergency department after being ill for 3 days. She had lived in an apartment with nine pet rats, and S. moniliformis was identified from the liver and kidney on autopsy.

Petechial and pustular lesions appeared on the foot of this 6-year-old boy who liked to kiss his pet rat. Courtesy Dr. Felice C. Adler-Shohet

LAS VEGAS — If a child presents to your office with fever, chills, muscle pain, joint swelling/pain, and a skin rash and has a pet rat, consider rat bite fever, Dr. Jay M. Lieberman advised at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

In the summer of 2002, one of his colleagues at Miller Children's Hospital in Long Beach, Calif., consulted on a 6-year-old boy who was admitted with a 3-day history of fever as high as 103 and petechial and pustular lesions on his feet. He had initially complained of left ankle pain and refusal to walk and then had diffuse pain of the left knee, elbow, and wrist.

The boy's lab tests were normal except for a low blood platelet count (146,000/mcL of blood). Liver function tests also were normal. The family was from Pennsylvania and had been living in southern California for 2 months. The patient had a pet rat that the family had acquired several weeks before the onset of his symptoms.

“This boy liked to kiss his rat,” said Dr. Lieberman, chief of pediatric infectious diseases at the hospital.

The history of the pet rat prompted Dr. Lieberman's colleague to review the medical literature on rat bite fever, and it became apparent that the boy had a classic presentation of the disease. Rat bite fever is caused by Streptobacillus moniliformis, a bacterium that is found in the normal oral flora of rats and can be excreted in rat urine.

Humans can become infected with S. moniliformis after a bite or scratch from the infected rat, from handling it, or by ingesting food or water contaminated with rat excrement.

The incubation period ranges from 2 to 10 days and patients present with a flu-like illness, including an abrupt onset of fever, chills, headache, and myalgia. A rash may develop 2–4 days after the onset of fever.

The rash “is usually maculopapular, predominantly involves the palms and soles, and may evolve into petechia, purpura, and vesicles,” said Dr. Lieberman, who also is a professor of pediatrics at the University of California, Irvine.

Penicillin G is the treatment of choice, and the boy improved rapidly once on the regimen. Untreated, the infection may have a relapsing course for 3 weeks or more with a case fatality rate as high as 10%.

Dr. Lieberman said the case underscores the importance of asking about pets in every febrile patient and considering the possibility of rat bite fever in acutely ill patients with rat exposure.

According to the textbooks, “children inhabiting crowded urban dwellings or rural areas infested with wild rats” are at risk. Half or more of wild rats carry the organism in their nasopharynx, Dr. Lieberman explained.

According to the Centers for Disease Control and Prevention, two people died from rat bite fever in 2003 (MMWR 2005;53:1198–202). One of the victims, a previously healthy 19-year-old woman in Washington, was pronounced dead upon arrival at a hospital emergency department after being ill for 3 days. She had lived in an apartment with nine pet rats, and S. moniliformis was identified from the liver and kidney on autopsy.

Petechial and pustular lesions appeared on the foot of this 6-year-old boy who liked to kiss his pet rat. Courtesy Dr. Felice C. Adler-Shohet

LAS VEGAS — If a child presents to your office with fever, chills, muscle pain, joint swelling/pain, and a skin rash and has a pet rat, consider rat bite fever, Dr. Jay M. Lieberman advised at a meeting sponsored by the American Academy of Pediatrics' California Chapters 1, 2, 3, and 4 and the AAP.

In the summer of 2002, one of his colleagues at Miller Children's Hospital in Long Beach, Calif., consulted on a 6-year-old boy who was admitted with a 3-day history of fever as high as 103 and petechial and pustular lesions on his feet. He had initially complained of left ankle pain and refusal to walk and then had diffuse pain of the left knee, elbow, and wrist.

The boy's lab tests were normal except for a low blood platelet count (146,000/mcL of blood). Liver function tests also were normal. The family was from Pennsylvania and had been living in southern California for 2 months. The patient had a pet rat that the family had acquired several weeks before the onset of his symptoms.

“This boy liked to kiss his rat,” said Dr. Lieberman, chief of pediatric infectious diseases at the hospital.

The history of the pet rat prompted Dr. Lieberman's colleague to review the medical literature on rat bite fever, and it became apparent that the boy had a classic presentation of the disease. Rat bite fever is caused by Streptobacillus moniliformis, a bacterium that is found in the normal oral flora of rats and can be excreted in rat urine.

Humans can become infected with S. moniliformis after a bite or scratch from the infected rat, from handling it, or by ingesting food or water contaminated with rat excrement.

The incubation period ranges from 2 to 10 days and patients present with a flu-like illness, including an abrupt onset of fever, chills, headache, and myalgia. A rash may develop 2–4 days after the onset of fever.

The rash “is usually maculopapular, predominantly involves the palms and soles, and may evolve into petechia, purpura, and vesicles,” said Dr. Lieberman, who also is a professor of pediatrics at the University of California, Irvine.

Penicillin G is the treatment of choice, and the boy improved rapidly once on the regimen. Untreated, the infection may have a relapsing course for 3 weeks or more with a case fatality rate as high as 10%.

Dr. Lieberman said the case underscores the importance of asking about pets in every febrile patient and considering the possibility of rat bite fever in acutely ill patients with rat exposure.

According to the textbooks, “children inhabiting crowded urban dwellings or rural areas infested with wild rats” are at risk. Half or more of wild rats carry the organism in their nasopharynx, Dr. Lieberman explained.

According to the Centers for Disease Control and Prevention, two people died from rat bite fever in 2003 (MMWR 2005;53:1198–202). One of the victims, a previously healthy 19-year-old woman in Washington, was pronounced dead upon arrival at a hospital emergency department after being ill for 3 days. She had lived in an apartment with nine pet rats, and S. moniliformis was identified from the liver and kidney on autopsy.

Petechial and pustular lesions appeared on the foot of this 6-year-old boy who liked to kiss his pet rat. Courtesy Dr. Felice C. Adler-Shohet

SAN DIEGO — The Patient Health Questionnaire 9-item depression scale detected major depression in 29% of epilepsy patients, results from a large single-center study showed.

Moreover, 52% of patients who had scores consistent with major depression were not on antidepressant medications, Dr. Nicole A. Seminario reported in a poster session at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

“It's important to be able to identify those people,” she said in an interview. “This scale is nice because you can hand it out to your patients in the clinic, and it's not as time consuming as a lot of the other inventories.”

Adapted from the Prime-MD patient health questionnaire, the self-administered Patient Health Questionnaire 9-item depression scale (PHQ-9) was first described in psychiatric literature (Psychiatr. Ann. 2002;32:509–21). It has been validated in the general population, indicating a prevalence rate of 9.2% for a current depressive disorder and a prevalence rate of 3.8% for major depression.

Dr. Seminario and her associates used the survey to determine the prevalence of major depression in 229 patients seen at the epilepsy clinic of the University of California, Davis, between May and November of 2005, including those seen for the first time and those seen for follow-up visits.

The patients filled out the PHQ-9 in the waiting room. The mean age of patients was 41 years, and 51% were female.

The researchers defined major depression as having a PHQ-9 score of 10 or higher (based on a scale of 0–27), as has been previously recommended in the medical literature.

Of the 229 patients, 67 (29%) had PHQ-9 scores of 10 or higher, reported Dr. Seminario, of the department of neurology at the University of California, Davis. Of these 67 patients, 35 (52%) were not on antidepressant medications, which suggests that they were undertreated. In addition, the mean depression scores were significantly higher in survey respondents who were on antidepressants, compared with those who were not taking antidepressants.

Depression status did not vary by type of antiepileptic medication used.

Patients with nonepileptic seizures were more likely to have depression than were their counterparts with other forms—localization related, idiopathic generalized, symptomatic generalized, and undetermined—of epilepsy. There were no other significant differences in depression scores among any of the other epilepsy groups.

“Our findings suggest that depression has a stronger association with lack of seizure freedom rather than the burden of antiepileptic drugs,” the researchers wrote. “There was no difference in depression score between patients on various monotherapies suggesting that the depression scores did not relate to particular side effects of the antiepileptic medications.”

SAN DIEGO — The Patient Health Questionnaire 9-item depression scale detected major depression in 29% of epilepsy patients, results from a large single-center study showed.

Moreover, 52% of patients who had scores consistent with major depression were not on antidepressant medications, Dr. Nicole A. Seminario reported in a poster session at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

“It's important to be able to identify those people,” she said in an interview. “This scale is nice because you can hand it out to your patients in the clinic, and it's not as time consuming as a lot of the other inventories.”

Adapted from the Prime-MD patient health questionnaire, the self-administered Patient Health Questionnaire 9-item depression scale (PHQ-9) was first described in psychiatric literature (Psychiatr. Ann. 2002;32:509–21). It has been validated in the general population, indicating a prevalence rate of 9.2% for a current depressive disorder and a prevalence rate of 3.8% for major depression.

Dr. Seminario and her associates used the survey to determine the prevalence of major depression in 229 patients seen at the epilepsy clinic of the University of California, Davis, between May and November of 2005, including those seen for the first time and those seen for follow-up visits.

The patients filled out the PHQ-9 in the waiting room. The mean age of patients was 41 years, and 51% were female.

The researchers defined major depression as having a PHQ-9 score of 10 or higher (based on a scale of 0–27), as has been previously recommended in the medical literature.

Of the 229 patients, 67 (29%) had PHQ-9 scores of 10 or higher, reported Dr. Seminario, of the department of neurology at the University of California, Davis. Of these 67 patients, 35 (52%) were not on antidepressant medications, which suggests that they were undertreated. In addition, the mean depression scores were significantly higher in survey respondents who were on antidepressants, compared with those who were not taking antidepressants.

Depression status did not vary by type of antiepileptic medication used.

Patients with nonepileptic seizures were more likely to have depression than were their counterparts with other forms—localization related, idiopathic generalized, symptomatic generalized, and undetermined—of epilepsy. There were no other significant differences in depression scores among any of the other epilepsy groups.

“Our findings suggest that depression has a stronger association with lack of seizure freedom rather than the burden of antiepileptic drugs,” the researchers wrote. “There was no difference in depression score between patients on various monotherapies suggesting that the depression scores did not relate to particular side effects of the antiepileptic medications.”

SAN DIEGO — The Patient Health Questionnaire 9-item depression scale detected major depression in 29% of epilepsy patients, results from a large single-center study showed.

Moreover, 52% of patients who had scores consistent with major depression were not on antidepressant medications, Dr. Nicole A. Seminario reported in a poster session at the annual meetings of the American Epilepsy Society and the Canadian League Against Epilepsy.

“It's important to be able to identify those people,” she said in an interview. “This scale is nice because you can hand it out to your patients in the clinic, and it's not as time consuming as a lot of the other inventories.”

Adapted from the Prime-MD patient health questionnaire, the self-administered Patient Health Questionnaire 9-item depression scale (PHQ-9) was first described in psychiatric literature (Psychiatr. Ann. 2002;32:509–21). It has been validated in the general population, indicating a prevalence rate of 9.2% for a current depressive disorder and a prevalence rate of 3.8% for major depression.

Dr. Seminario and her associates used the survey to determine the prevalence of major depression in 229 patients seen at the epilepsy clinic of the University of California, Davis, between May and November of 2005, including those seen for the first time and those seen for follow-up visits.

The patients filled out the PHQ-9 in the waiting room. The mean age of patients was 41 years, and 51% were female.

The researchers defined major depression as having a PHQ-9 score of 10 or higher (based on a scale of 0–27), as has been previously recommended in the medical literature.

Of the 229 patients, 67 (29%) had PHQ-9 scores of 10 or higher, reported Dr. Seminario, of the department of neurology at the University of California, Davis. Of these 67 patients, 35 (52%) were not on antidepressant medications, which suggests that they were undertreated. In addition, the mean depression scores were significantly higher in survey respondents who were on antidepressants, compared with those who were not taking antidepressants.

Depression status did not vary by type of antiepileptic medication used.

Patients with nonepileptic seizures were more likely to have depression than were their counterparts with other forms—localization related, idiopathic generalized, symptomatic generalized, and undetermined—of epilepsy. There were no other significant differences in depression scores among any of the other epilepsy groups.

“Our findings suggest that depression has a stronger association with lack of seizure freedom rather than the burden of antiepileptic drugs,” the researchers wrote. “There was no difference in depression score between patients on various monotherapies suggesting that the depression scores did not relate to particular side effects of the antiepileptic medications.”