Patrice Wendling

Routine use of seven-valent pneumococcal conjugate vaccine in young children has dramatically reduced the incidence of vaccine-type and overall invasive pneumococcal disease in children and adults, the Centers for Disease Control and Prevention reported.

The most substantial decline in the rate of vaccine-type disease has been in the target population of children less than 5 years old, according to an analysis comparing disease rates in 2003 with those in 1998–1999, when the Prevnar vaccine was not available.

In this age group, vaccine-type invasive pneumococcal disease (IPD) decreased 94% from 80 cases per 100,000 population to 4.6 cases (MMWR 2005;54:893–7).

Incidence rates of vaccine-type IPD also declined substantially among individuals outside the target population, with the largest absolute rate reduction occurring in those 65 years and older.

The routine use of the vaccine prevented 29,599 expected vaccine-type IPD cases in 2003, according to the analysis conducted by the Active Bacterial Core surveillance of the Emerging Infections Program Network in cooperation with the CDC.

An estimated 9,140 cases of vaccine-type IPD were directly prevented by vaccinating children less than 5 years old. An additional 20,459 cases (69%) were prevented through indirect effects of the vaccine across all ages.

“This is not the first vaccine to be shown to have a herd immunity effect, but the magnitude of the effect being so large is what makes this vaccine important,” Deron C. Burton, M.D., of the CDC's division of bacterial and mycotic diseases, said in an interview.

Among children less than 5 years old and adults aged 40 years or older, the reduction in vaccine-type IPD was offset by an increase in disease caused by pneumococcal serotypes not included in the seven-valent vaccine. There were a total of 4,721 projected additional cases of nonvaccine-type IPD across all age groups in 2003, compared with baseline.

Dr. Burton said ongoing surveillance will be required to determine if the replacement disease effect stays small or if it increases in magnitude and begins to erode some of the benefits of the vaccine.

Routine use of seven-valent pneumococcal conjugate vaccine in young children has dramatically reduced the incidence of vaccine-type and overall invasive pneumococcal disease in children and adults, the Centers for Disease Control and Prevention reported.

The most substantial decline in the rate of vaccine-type disease has been in the target population of children less than 5 years old, according to an analysis comparing disease rates in 2003 with those in 1998–1999, when the Prevnar vaccine was not available.

In this age group, vaccine-type invasive pneumococcal disease (IPD) decreased 94% from 80 cases per 100,000 population to 4.6 cases (MMWR 2005;54:893–7).

Incidence rates of vaccine-type IPD also declined substantially among individuals outside the target population, with the largest absolute rate reduction occurring in those 65 years and older.

The routine use of the vaccine prevented 29,599 expected vaccine-type IPD cases in 2003, according to the analysis conducted by the Active Bacterial Core surveillance of the Emerging Infections Program Network in cooperation with the CDC.

An estimated 9,140 cases of vaccine-type IPD were directly prevented by vaccinating children less than 5 years old. An additional 20,459 cases (69%) were prevented through indirect effects of the vaccine across all ages.

“This is not the first vaccine to be shown to have a herd immunity effect, but the magnitude of the effect being so large is what makes this vaccine important,” Deron C. Burton, M.D., of the CDC's division of bacterial and mycotic diseases, said in an interview.

Among children less than 5 years old and adults aged 40 years or older, the reduction in vaccine-type IPD was offset by an increase in disease caused by pneumococcal serotypes not included in the seven-valent vaccine. There were a total of 4,721 projected additional cases of nonvaccine-type IPD across all age groups in 2003, compared with baseline.

Dr. Burton said ongoing surveillance will be required to determine if the replacement disease effect stays small or if it increases in magnitude and begins to erode some of the benefits of the vaccine.

Routine use of seven-valent pneumococcal conjugate vaccine in young children has dramatically reduced the incidence of vaccine-type and overall invasive pneumococcal disease in children and adults, the Centers for Disease Control and Prevention reported.

The most substantial decline in the rate of vaccine-type disease has been in the target population of children less than 5 years old, according to an analysis comparing disease rates in 2003 with those in 1998–1999, when the Prevnar vaccine was not available.

In this age group, vaccine-type invasive pneumococcal disease (IPD) decreased 94% from 80 cases per 100,000 population to 4.6 cases (MMWR 2005;54:893–7).

Incidence rates of vaccine-type IPD also declined substantially among individuals outside the target population, with the largest absolute rate reduction occurring in those 65 years and older.

The routine use of the vaccine prevented 29,599 expected vaccine-type IPD cases in 2003, according to the analysis conducted by the Active Bacterial Core surveillance of the Emerging Infections Program Network in cooperation with the CDC.

An estimated 9,140 cases of vaccine-type IPD were directly prevented by vaccinating children less than 5 years old. An additional 20,459 cases (69%) were prevented through indirect effects of the vaccine across all ages.

“This is not the first vaccine to be shown to have a herd immunity effect, but the magnitude of the effect being so large is what makes this vaccine important,” Deron C. Burton, M.D., of the CDC's division of bacterial and mycotic diseases, said in an interview.

Among children less than 5 years old and adults aged 40 years or older, the reduction in vaccine-type IPD was offset by an increase in disease caused by pneumococcal serotypes not included in the seven-valent vaccine. There were a total of 4,721 projected additional cases of nonvaccine-type IPD across all age groups in 2003, compared with baseline.

Dr. Burton said ongoing surveillance will be required to determine if the replacement disease effect stays small or if it increases in magnitude and begins to erode some of the benefits of the vaccine.

LOS ANGELES — Large meningiomas can be resected with good long-term outcomes and without damage to the facial nerve using a combined retrosigmoid-transpetrosal-transchochlear approach, Rita M. Schuman, M.D., reported.

Large meningiomas located in the space between the cerebellum and the pons can originate from any area of the dura on the posterior surface of the petrous bone. Tumor removal is surgically challenging due to tumor vascularity, neural attachment, and brainstem compression.

Surgeons at the Loyola Center for Cranial Base Surgery in Maywood, Ill., combined several traditional approaches in a single-stage procedure, employing both retrosigmoid and presigmoid dural openings in 29 patients with large meningiomas of the cerebellopontine angle. The combined approach allows for wider access.

The approach was selected because of the combination of poor hearing and large tumor size among the patients, Dr. Schuman, a resident, said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Tumors ranged in size from 3 cm to 4 cm (8 cases), 4.1 cm to 5 cm (14), 5.1 cm to 6 cm (4), and 6 cm or larger (3), according to a chart review from July 1995 to July 2004.

The most common presenting symptoms were hearing loss (25 patients) and unilateral tinnitus (22 patients). Only six patients had no cranial nerve involvement upon presentation.

Complete tumor removal was achieved in 19 of 29 (66%) patients, near-total removal in 7 (24%), and subtotal removal in 3 (10%).

Postoperative sequelae included three cases of facial paralysis (10.3%), one case of cranial nerve grade 5 deficit (3.4%), two cranial nerve grade 6 deficits (6.9%), one case of vocal cord paralysis (3.4%), and one of cerebrospinal fluid fistula (3.4%).

The facial nerve was preserved despite the surgery in 26 of 29 patients. At the 2-year follow-up, 20 of the patients with an intact facial nerve had good function in that nerve, and 6 had adequate function.

With an average of 4.6 years follow-up, there was no residual tumor in 19 patients; the tumors were stable in another six patients, and there were signs of tumor regrowth in four (13.8%) patients.

“[The] three different approaches together [provide] the neurosurgeon with a wider lateral access to the tumor, and long-term follow-up shows the recurrence rate is low, and the total tumor removal rate is high,” lead author John P. Leonetti, M.D., director of the Center and professor of otolaryngology at Loyola University, said in an interview.

CPA meningioma with internal auditory canal extension seen on axial MRI.

Complete resection of the meningioma is evident on postoperative CT scan. Photos courtesy Dr. John P. Leonetti

LOS ANGELES — Large meningiomas can be resected with good long-term outcomes and without damage to the facial nerve using a combined retrosigmoid-transpetrosal-transchochlear approach, Rita M. Schuman, M.D., reported.

Large meningiomas located in the space between the cerebellum and the pons can originate from any area of the dura on the posterior surface of the petrous bone. Tumor removal is surgically challenging due to tumor vascularity, neural attachment, and brainstem compression.

Surgeons at the Loyola Center for Cranial Base Surgery in Maywood, Ill., combined several traditional approaches in a single-stage procedure, employing both retrosigmoid and presigmoid dural openings in 29 patients with large meningiomas of the cerebellopontine angle. The combined approach allows for wider access.

The approach was selected because of the combination of poor hearing and large tumor size among the patients, Dr. Schuman, a resident, said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Tumors ranged in size from 3 cm to 4 cm (8 cases), 4.1 cm to 5 cm (14), 5.1 cm to 6 cm (4), and 6 cm or larger (3), according to a chart review from July 1995 to July 2004.

The most common presenting symptoms were hearing loss (25 patients) and unilateral tinnitus (22 patients). Only six patients had no cranial nerve involvement upon presentation.

Complete tumor removal was achieved in 19 of 29 (66%) patients, near-total removal in 7 (24%), and subtotal removal in 3 (10%).

Postoperative sequelae included three cases of facial paralysis (10.3%), one case of cranial nerve grade 5 deficit (3.4%), two cranial nerve grade 6 deficits (6.9%), one case of vocal cord paralysis (3.4%), and one of cerebrospinal fluid fistula (3.4%).

The facial nerve was preserved despite the surgery in 26 of 29 patients. At the 2-year follow-up, 20 of the patients with an intact facial nerve had good function in that nerve, and 6 had adequate function.

With an average of 4.6 years follow-up, there was no residual tumor in 19 patients; the tumors were stable in another six patients, and there were signs of tumor regrowth in four (13.8%) patients.

“[The] three different approaches together [provide] the neurosurgeon with a wider lateral access to the tumor, and long-term follow-up shows the recurrence rate is low, and the total tumor removal rate is high,” lead author John P. Leonetti, M.D., director of the Center and professor of otolaryngology at Loyola University, said in an interview.

CPA meningioma with internal auditory canal extension seen on axial MRI.

Complete resection of the meningioma is evident on postoperative CT scan. Photos courtesy Dr. John P. Leonetti

LOS ANGELES — Large meningiomas can be resected with good long-term outcomes and without damage to the facial nerve using a combined retrosigmoid-transpetrosal-transchochlear approach, Rita M. Schuman, M.D., reported.

Large meningiomas located in the space between the cerebellum and the pons can originate from any area of the dura on the posterior surface of the petrous bone. Tumor removal is surgically challenging due to tumor vascularity, neural attachment, and brainstem compression.

Surgeons at the Loyola Center for Cranial Base Surgery in Maywood, Ill., combined several traditional approaches in a single-stage procedure, employing both retrosigmoid and presigmoid dural openings in 29 patients with large meningiomas of the cerebellopontine angle. The combined approach allows for wider access.

The approach was selected because of the combination of poor hearing and large tumor size among the patients, Dr. Schuman, a resident, said at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

Tumors ranged in size from 3 cm to 4 cm (8 cases), 4.1 cm to 5 cm (14), 5.1 cm to 6 cm (4), and 6 cm or larger (3), according to a chart review from July 1995 to July 2004.

The most common presenting symptoms were hearing loss (25 patients) and unilateral tinnitus (22 patients). Only six patients had no cranial nerve involvement upon presentation.

Complete tumor removal was achieved in 19 of 29 (66%) patients, near-total removal in 7 (24%), and subtotal removal in 3 (10%).

Postoperative sequelae included three cases of facial paralysis (10.3%), one case of cranial nerve grade 5 deficit (3.4%), two cranial nerve grade 6 deficits (6.9%), one case of vocal cord paralysis (3.4%), and one of cerebrospinal fluid fistula (3.4%).

The facial nerve was preserved despite the surgery in 26 of 29 patients. At the 2-year follow-up, 20 of the patients with an intact facial nerve had good function in that nerve, and 6 had adequate function.

With an average of 4.6 years follow-up, there was no residual tumor in 19 patients; the tumors were stable in another six patients, and there were signs of tumor regrowth in four (13.8%) patients.

“[The] three different approaches together [provide] the neurosurgeon with a wider lateral access to the tumor, and long-term follow-up shows the recurrence rate is low, and the total tumor removal rate is high,” lead author John P. Leonetti, M.D., director of the Center and professor of otolaryngology at Loyola University, said in an interview.

CPA meningioma with internal auditory canal extension seen on axial MRI.

Complete resection of the meningioma is evident on postoperative CT scan. Photos courtesy Dr. John P. Leonetti

In the wake of hurricane Katrina, 22 new cases of Vibrio illness with five deaths were identified during August 29 to September 11, according to government health sources.

The illnesses were caused by Vibrio vulnificus, V. parahaemolyticus, and nontoxigenic V. cholerae. (MMWR 2005;54:928–31).

These organisms are acquired from the environment and are unlikely to cause outbreaks from person-to-person transmission.

No cases of toxigenic V. cholerae serogroups O1 or O139, the agents that cause cholera, were identified.

No confirmed cases of illness have been identified with onset after Sept. 5, although additional cases were under investigation at press time.

Of the 22 confirmed cases, 18 were wound-associated Vibrio cases reported in residents or displaced persons from Mississippi or Louisiana.

Five patients (28%) with wound-associated Vibrio infections died, according to an investigation by state and local health departments and the Centers for Disease Control and Prevention. Three of the deaths were associated with V. vulnificus infection and two with V. parahaemolyticus infection.

Whether acquired through wound infection or ingestion, V. vulnificus typically causes a severe and life-threatening illness characterized by fever, chills, decreased blood pressure, and blood-tinged blistering skin lesions.

V. parahaemolyticus typically causes gastroenteritis after consumption of contaminated shellfish. Wound infections are less common from this organism and are generally less severe.

Nontoxigenic V. cholerae causes primarily gastroenteritis and has rarely been reported to cause wound infections.

All three organisms can result in more severe infections in patients with liver disease or who are immunocompromised.

An underlying condition that might have increased the risk for severe Vibrio illness was reported in 13 (72%) of the patients with wounds.

Vibrio infections are diagnosed by culture of wound, blood, or stool specimens. For stool samples, health officials recommend a selective media of thiosulfate-citrate-bile salts-sucrose agar.

Clinical laboratories are advised to send all Vibrio isolates to state public health laboratories for confirmation.

Nationwide, an average of 412 cases from Vibrio species other than toxigenic V. cholerae O1 or O139 were reported each year during 2000 to 2004, including an average of 146 cases reported in the five Gulf Coast states.

In areas where floodwaters have receded and surfaces are dry, Vibrio should not be a concern, because the organism is killed rapidly by drying.

In the wake of hurricane Katrina, 22 new cases of Vibrio illness with five deaths were identified during August 29 to September 11, according to government health sources.

The illnesses were caused by Vibrio vulnificus, V. parahaemolyticus, and nontoxigenic V. cholerae. (MMWR 2005;54:928–31).

These organisms are acquired from the environment and are unlikely to cause outbreaks from person-to-person transmission.

No cases of toxigenic V. cholerae serogroups O1 or O139, the agents that cause cholera, were identified.

No confirmed cases of illness have been identified with onset after Sept. 5, although additional cases were under investigation at press time.

Of the 22 confirmed cases, 18 were wound-associated Vibrio cases reported in residents or displaced persons from Mississippi or Louisiana.

Five patients (28%) with wound-associated Vibrio infections died, according to an investigation by state and local health departments and the Centers for Disease Control and Prevention. Three of the deaths were associated with V. vulnificus infection and two with V. parahaemolyticus infection.

Whether acquired through wound infection or ingestion, V. vulnificus typically causes a severe and life-threatening illness characterized by fever, chills, decreased blood pressure, and blood-tinged blistering skin lesions.

V. parahaemolyticus typically causes gastroenteritis after consumption of contaminated shellfish. Wound infections are less common from this organism and are generally less severe.

Nontoxigenic V. cholerae causes primarily gastroenteritis and has rarely been reported to cause wound infections.

All three organisms can result in more severe infections in patients with liver disease or who are immunocompromised.

An underlying condition that might have increased the risk for severe Vibrio illness was reported in 13 (72%) of the patients with wounds.

Vibrio infections are diagnosed by culture of wound, blood, or stool specimens. For stool samples, health officials recommend a selective media of thiosulfate-citrate-bile salts-sucrose agar.

Clinical laboratories are advised to send all Vibrio isolates to state public health laboratories for confirmation.

Nationwide, an average of 412 cases from Vibrio species other than toxigenic V. cholerae O1 or O139 were reported each year during 2000 to 2004, including an average of 146 cases reported in the five Gulf Coast states.

In areas where floodwaters have receded and surfaces are dry, Vibrio should not be a concern, because the organism is killed rapidly by drying.

In the wake of hurricane Katrina, 22 new cases of Vibrio illness with five deaths were identified during August 29 to September 11, according to government health sources.

The illnesses were caused by Vibrio vulnificus, V. parahaemolyticus, and nontoxigenic V. cholerae. (MMWR 2005;54:928–31).

These organisms are acquired from the environment and are unlikely to cause outbreaks from person-to-person transmission.

No cases of toxigenic V. cholerae serogroups O1 or O139, the agents that cause cholera, were identified.

No confirmed cases of illness have been identified with onset after Sept. 5, although additional cases were under investigation at press time.

Of the 22 confirmed cases, 18 were wound-associated Vibrio cases reported in residents or displaced persons from Mississippi or Louisiana.

Five patients (28%) with wound-associated Vibrio infections died, according to an investigation by state and local health departments and the Centers for Disease Control and Prevention. Three of the deaths were associated with V. vulnificus infection and two with V. parahaemolyticus infection.

Whether acquired through wound infection or ingestion, V. vulnificus typically causes a severe and life-threatening illness characterized by fever, chills, decreased blood pressure, and blood-tinged blistering skin lesions.

V. parahaemolyticus typically causes gastroenteritis after consumption of contaminated shellfish. Wound infections are less common from this organism and are generally less severe.

Nontoxigenic V. cholerae causes primarily gastroenteritis and has rarely been reported to cause wound infections.

All three organisms can result in more severe infections in patients with liver disease or who are immunocompromised.

An underlying condition that might have increased the risk for severe Vibrio illness was reported in 13 (72%) of the patients with wounds.

Vibrio infections are diagnosed by culture of wound, blood, or stool specimens. For stool samples, health officials recommend a selective media of thiosulfate-citrate-bile salts-sucrose agar.

Clinical laboratories are advised to send all Vibrio isolates to state public health laboratories for confirmation.

Nationwide, an average of 412 cases from Vibrio species other than toxigenic V. cholerae O1 or O139 were reported each year during 2000 to 2004, including an average of 146 cases reported in the five Gulf Coast states.

In areas where floodwaters have receded and surfaces are dry, Vibrio should not be a concern, because the organism is killed rapidly by drying.

CHICAGO — Evidence is mounting that biologic therapies such as alefacept and efalizumab can successfully treat palmoplantar pustular psoriasis.

Preliminary data from a pilot study of 15 patients at two sites showed a 16-week course of alefacept (Amevive), including 8 weeks of alefacept 30 mg once weekly, resulted in substantial improvements in clinical outcomes, Daniel Pearce, M.D., reported in a poster at the American Academy of Dermatology's Academy 2005 meeting.

The mean improvement in palmoplantar psoriasis severity instrument (PPSI) scores was 18% among nine patients at site A and 45% among six patients at site B.

Physician's global assessment (PGA) of palmoplantar psoriasis improved significantly at site A from 2.3 at week 4 to 1.8 at week 28, and improved at site B from 2.4 at week 4 to 2.0 at week 16.

Patients in this study were injected intramuscularly with 15 mg/wk of alefacept for 16 weeks, compared with the recommended 12-week course for adult psoriasis patients.

The dose was increased in the majority of patients to 30 mg/wk at 8 weeks due to a limited response.

All patients were allowed to remain on methotrexate 25 mg/wk or less or acitretin 50 mg/day or less during the trial, sponsored by Biogen Idec Inc., which markets Amevive and is headquartered in Cambridge, Mass.

There was no plateau in response for PPSI and PGA scores at week 16, suggesting that the longer treatment may possibly offer greater benefit for some patients, reported Dr. Pearce of the Center for Dermatology Research at Wake Forest University, Winston-Salem, N.C.

CD4 T-cell counts were predictably reduced by alefacept. But no patient had CD4 T-cell counts less than 250 cells/mm

In a separate poster that was reported at the same meeting, a 50-year-old patient remained clear of palmoplantar pustular psoriasis 11 months after beginning treatment with efalizumab (Raptiva).

The patient remains on continuous efalizumab therapy and is currently able to walk without pain as well as being able to use her hands again, reported Loretta A. Jones, a nurse practitioner at the Abilene (Texas) Dermatology and Skin Surgery Center.

A response was observed in 1 month of initiating subcutaneous efalizumab 1 mg/kg per week, and the patient was asymptomatic after 5 months.

There were neither any flares nor any adverse events attributed to the drug, according to the poster, which was developed with support from Genentech Inc. of South San Francisco, Calif., which markets Raptiva.

CHICAGO — Evidence is mounting that biologic therapies such as alefacept and efalizumab can successfully treat palmoplantar pustular psoriasis.

Preliminary data from a pilot study of 15 patients at two sites showed a 16-week course of alefacept (Amevive), including 8 weeks of alefacept 30 mg once weekly, resulted in substantial improvements in clinical outcomes, Daniel Pearce, M.D., reported in a poster at the American Academy of Dermatology's Academy 2005 meeting.

The mean improvement in palmoplantar psoriasis severity instrument (PPSI) scores was 18% among nine patients at site A and 45% among six patients at site B.

Physician's global assessment (PGA) of palmoplantar psoriasis improved significantly at site A from 2.3 at week 4 to 1.8 at week 28, and improved at site B from 2.4 at week 4 to 2.0 at week 16.

Patients in this study were injected intramuscularly with 15 mg/wk of alefacept for 16 weeks, compared with the recommended 12-week course for adult psoriasis patients.

The dose was increased in the majority of patients to 30 mg/wk at 8 weeks due to a limited response.

All patients were allowed to remain on methotrexate 25 mg/wk or less or acitretin 50 mg/day or less during the trial, sponsored by Biogen Idec Inc., which markets Amevive and is headquartered in Cambridge, Mass.

There was no plateau in response for PPSI and PGA scores at week 16, suggesting that the longer treatment may possibly offer greater benefit for some patients, reported Dr. Pearce of the Center for Dermatology Research at Wake Forest University, Winston-Salem, N.C.

CD4 T-cell counts were predictably reduced by alefacept. But no patient had CD4 T-cell counts less than 250 cells/mm

In a separate poster that was reported at the same meeting, a 50-year-old patient remained clear of palmoplantar pustular psoriasis 11 months after beginning treatment with efalizumab (Raptiva).

The patient remains on continuous efalizumab therapy and is currently able to walk without pain as well as being able to use her hands again, reported Loretta A. Jones, a nurse practitioner at the Abilene (Texas) Dermatology and Skin Surgery Center.

A response was observed in 1 month of initiating subcutaneous efalizumab 1 mg/kg per week, and the patient was asymptomatic after 5 months.

There were neither any flares nor any adverse events attributed to the drug, according to the poster, which was developed with support from Genentech Inc. of South San Francisco, Calif., which markets Raptiva.

CHICAGO — Evidence is mounting that biologic therapies such as alefacept and efalizumab can successfully treat palmoplantar pustular psoriasis.

Preliminary data from a pilot study of 15 patients at two sites showed a 16-week course of alefacept (Amevive), including 8 weeks of alefacept 30 mg once weekly, resulted in substantial improvements in clinical outcomes, Daniel Pearce, M.D., reported in a poster at the American Academy of Dermatology's Academy 2005 meeting.

The mean improvement in palmoplantar psoriasis severity instrument (PPSI) scores was 18% among nine patients at site A and 45% among six patients at site B.

Physician's global assessment (PGA) of palmoplantar psoriasis improved significantly at site A from 2.3 at week 4 to 1.8 at week 28, and improved at site B from 2.4 at week 4 to 2.0 at week 16.

Patients in this study were injected intramuscularly with 15 mg/wk of alefacept for 16 weeks, compared with the recommended 12-week course for adult psoriasis patients.

The dose was increased in the majority of patients to 30 mg/wk at 8 weeks due to a limited response.

All patients were allowed to remain on methotrexate 25 mg/wk or less or acitretin 50 mg/day or less during the trial, sponsored by Biogen Idec Inc., which markets Amevive and is headquartered in Cambridge, Mass.

There was no plateau in response for PPSI and PGA scores at week 16, suggesting that the longer treatment may possibly offer greater benefit for some patients, reported Dr. Pearce of the Center for Dermatology Research at Wake Forest University, Winston-Salem, N.C.

CD4 T-cell counts were predictably reduced by alefacept. But no patient had CD4 T-cell counts less than 250 cells/mm

In a separate poster that was reported at the same meeting, a 50-year-old patient remained clear of palmoplantar pustular psoriasis 11 months after beginning treatment with efalizumab (Raptiva).

The patient remains on continuous efalizumab therapy and is currently able to walk without pain as well as being able to use her hands again, reported Loretta A. Jones, a nurse practitioner at the Abilene (Texas) Dermatology and Skin Surgery Center.

A response was observed in 1 month of initiating subcutaneous efalizumab 1 mg/kg per week, and the patient was asymptomatic after 5 months.

There were neither any flares nor any adverse events attributed to the drug, according to the poster, which was developed with support from Genentech Inc. of South San Francisco, Calif., which markets Raptiva.

CHICAGO — Maintaining patients with moderate to severe psoriasis on a higher than recommended dose of etanercept is safe, according to new long-term multicenter phase III data.

Although the recommended dosing in the United States is for 3 months of 50 mg etanercept twice weekly, followed by a reduction to a maintenance dose of 50 mg per week, the current analysis evaluated 50 mg twice weekly through 48 weeks.

The study reflects the off-label use of etanercept (Enbrel) at the higher dose to tackle new lesions that develop in about half of patients and to maintain continuous insurance coverage.

“The most difficult thing is to justify to the insurance company that you need to put a patient back on 100 mg a week,” lead author Stephen Tyring, M.D., told this newspaper. “They won't pay for the 100 mg beyond the 3 months if you reduce it. If you just keep them on 100 mg, often they don't notice.”

This scenario has left physicians facing the most important question, which is whether the higher extended dosing is safe.

The safety is definitely indistinguishable from placebo, and there were twice as many patients as controls, said Dr. Tyring, who presented the data in a poster at the American Academy of Dermatology's Academy 2005 meeting.

The study randomized 307 patients to placebo and 311 patients to etanercept 50 mg twice weekly for 12 weeks.

A total of 599 patients continued in the ongoing open-label phase of the study in which patients continued on treatment or were switched from placebo to etanercept 50 mg twice weekly.

Analysis through week 48 showed there were no deaths and no cases of opportunistic infections, tuberculosis, demyelinating diseases, hematologic events, or congestive heart failure.

Dr. Tyring and colleagues at the University of Texas, Houston, perform chest x-rays and purified protein derivative TB skin tests as standard of care. But not all sites screened for TB, nor did they perform MRIs.

There have not been enough cases of multiple sclerosis in psoriasis patients using biologic therapies to determine if there is a cause-and-effect relationship or if it is just background, Dr. Tyring said.

For the time being, he does not treat psoriasis patients with etanercept if they have multiple sclerosis or if they have close family members who have multiple sclerosis.

There was one case of lymphoma in the study. Dr. Tyring said it was probably background, and noted that some studies put the risk of lymphoma in psoriasis patients as at least twice that of healthy controls.

In the double-blind period, nine patients discontinued because of an adverse event; 13 additional patients have since discontinued because of an adverse event.

Finally, the data showed that there was no diminished treatment effect from baseline, which has been a problem with some psoriasis treatments.

At week 48, dermatologists accessed about 55% of patients as clear or almost clear, whereas 65% of patients made the same assessment.

The study was funded by Immunex Corp., a subsidiary of Wyeth Research and Amgen Inc., which markets etanercept.

Dr. Tyring did not disclose any financial relationship to any of the three companies.

CHICAGO — Maintaining patients with moderate to severe psoriasis on a higher than recommended dose of etanercept is safe, according to new long-term multicenter phase III data.

Although the recommended dosing in the United States is for 3 months of 50 mg etanercept twice weekly, followed by a reduction to a maintenance dose of 50 mg per week, the current analysis evaluated 50 mg twice weekly through 48 weeks.

The study reflects the off-label use of etanercept (Enbrel) at the higher dose to tackle new lesions that develop in about half of patients and to maintain continuous insurance coverage.

“The most difficult thing is to justify to the insurance company that you need to put a patient back on 100 mg a week,” lead author Stephen Tyring, M.D., told this newspaper. “They won't pay for the 100 mg beyond the 3 months if you reduce it. If you just keep them on 100 mg, often they don't notice.”

This scenario has left physicians facing the most important question, which is whether the higher extended dosing is safe.

The safety is definitely indistinguishable from placebo, and there were twice as many patients as controls, said Dr. Tyring, who presented the data in a poster at the American Academy of Dermatology's Academy 2005 meeting.

The study randomized 307 patients to placebo and 311 patients to etanercept 50 mg twice weekly for 12 weeks.

A total of 599 patients continued in the ongoing open-label phase of the study in which patients continued on treatment or were switched from placebo to etanercept 50 mg twice weekly.

Analysis through week 48 showed there were no deaths and no cases of opportunistic infections, tuberculosis, demyelinating diseases, hematologic events, or congestive heart failure.

Dr. Tyring and colleagues at the University of Texas, Houston, perform chest x-rays and purified protein derivative TB skin tests as standard of care. But not all sites screened for TB, nor did they perform MRIs.

There have not been enough cases of multiple sclerosis in psoriasis patients using biologic therapies to determine if there is a cause-and-effect relationship or if it is just background, Dr. Tyring said.

For the time being, he does not treat psoriasis patients with etanercept if they have multiple sclerosis or if they have close family members who have multiple sclerosis.

There was one case of lymphoma in the study. Dr. Tyring said it was probably background, and noted that some studies put the risk of lymphoma in psoriasis patients as at least twice that of healthy controls.

In the double-blind period, nine patients discontinued because of an adverse event; 13 additional patients have since discontinued because of an adverse event.

Finally, the data showed that there was no diminished treatment effect from baseline, which has been a problem with some psoriasis treatments.

At week 48, dermatologists accessed about 55% of patients as clear or almost clear, whereas 65% of patients made the same assessment.

The study was funded by Immunex Corp., a subsidiary of Wyeth Research and Amgen Inc., which markets etanercept.

Dr. Tyring did not disclose any financial relationship to any of the three companies.

CHICAGO — Maintaining patients with moderate to severe psoriasis on a higher than recommended dose of etanercept is safe, according to new long-term multicenter phase III data.

Although the recommended dosing in the United States is for 3 months of 50 mg etanercept twice weekly, followed by a reduction to a maintenance dose of 50 mg per week, the current analysis evaluated 50 mg twice weekly through 48 weeks.

The study reflects the off-label use of etanercept (Enbrel) at the higher dose to tackle new lesions that develop in about half of patients and to maintain continuous insurance coverage.

“The most difficult thing is to justify to the insurance company that you need to put a patient back on 100 mg a week,” lead author Stephen Tyring, M.D., told this newspaper. “They won't pay for the 100 mg beyond the 3 months if you reduce it. If you just keep them on 100 mg, often they don't notice.”

This scenario has left physicians facing the most important question, which is whether the higher extended dosing is safe.

The safety is definitely indistinguishable from placebo, and there were twice as many patients as controls, said Dr. Tyring, who presented the data in a poster at the American Academy of Dermatology's Academy 2005 meeting.

The study randomized 307 patients to placebo and 311 patients to etanercept 50 mg twice weekly for 12 weeks.

A total of 599 patients continued in the ongoing open-label phase of the study in which patients continued on treatment or were switched from placebo to etanercept 50 mg twice weekly.

Analysis through week 48 showed there were no deaths and no cases of opportunistic infections, tuberculosis, demyelinating diseases, hematologic events, or congestive heart failure.

Dr. Tyring and colleagues at the University of Texas, Houston, perform chest x-rays and purified protein derivative TB skin tests as standard of care. But not all sites screened for TB, nor did they perform MRIs.

There have not been enough cases of multiple sclerosis in psoriasis patients using biologic therapies to determine if there is a cause-and-effect relationship or if it is just background, Dr. Tyring said.

For the time being, he does not treat psoriasis patients with etanercept if they have multiple sclerosis or if they have close family members who have multiple sclerosis.

There was one case of lymphoma in the study. Dr. Tyring said it was probably background, and noted that some studies put the risk of lymphoma in psoriasis patients as at least twice that of healthy controls.

In the double-blind period, nine patients discontinued because of an adverse event; 13 additional patients have since discontinued because of an adverse event.

Finally, the data showed that there was no diminished treatment effect from baseline, which has been a problem with some psoriasis treatments.

At week 48, dermatologists accessed about 55% of patients as clear or almost clear, whereas 65% of patients made the same assessment.

The study was funded by Immunex Corp., a subsidiary of Wyeth Research and Amgen Inc., which markets etanercept.

Dr. Tyring did not disclose any financial relationship to any of the three companies.

Routine use of seven-valent pneumococcal conjugate vaccine in young children has dramatically reduced the incidence of vaccine-type and overall invasive pneumococcal disease in children and adults, the Centers for Disease Control and Prevention reported.

The most substantial decline in the rate of vaccine-type disease has been in the target population of children less than 5 years old, according to an analysis comparing disease rates in 2003 with those in 1998–1999, when Prevnar was not available.

In this age group, vaccine-type invasive pneumococcal disease (IPD) decreased 94% from 80 cases per 100,000 population to 4.6 cases (MMWR 2005;54:893–7).

Incidence rates of vaccine-type IPD also declined among individuals outside the target population, with the largest reduction occurring in those 65 years and older.

The routine use of the vaccine prevented 29,599 expected vaccine-type IPD cases in 2003, according to the analysis conducted by the Active Bacterial Core surveillance of the Emerging Infections Program Network in cooperation with the CDC.

An estimated 9,140 cases of vaccine-type IPD were directly prevented by vaccinating children less than 5 years old. An additional 20,459 cases (69%) were prevented through indirect effects of the vaccine across all ages.

Among children less than 5 years old and adults aged 40 years or older, the reduction in vaccine-type IPD was offset by an increase in disease caused by pneumococcal serotypes not included in the seven-valent vaccine. There were a total of 4,721 projected additional cases of nonvaccine-type IPD across all age groups in 2003.

Routine use of seven-valent pneumococcal conjugate vaccine in young children has dramatically reduced the incidence of vaccine-type and overall invasive pneumococcal disease in children and adults, the Centers for Disease Control and Prevention reported.

The most substantial decline in the rate of vaccine-type disease has been in the target population of children less than 5 years old, according to an analysis comparing disease rates in 2003 with those in 1998–1999, when Prevnar was not available.

In this age group, vaccine-type invasive pneumococcal disease (IPD) decreased 94% from 80 cases per 100,000 population to 4.6 cases (MMWR 2005;54:893–7).

Incidence rates of vaccine-type IPD also declined among individuals outside the target population, with the largest reduction occurring in those 65 years and older.

The routine use of the vaccine prevented 29,599 expected vaccine-type IPD cases in 2003, according to the analysis conducted by the Active Bacterial Core surveillance of the Emerging Infections Program Network in cooperation with the CDC.

An estimated 9,140 cases of vaccine-type IPD were directly prevented by vaccinating children less than 5 years old. An additional 20,459 cases (69%) were prevented through indirect effects of the vaccine across all ages.

Among children less than 5 years old and adults aged 40 years or older, the reduction in vaccine-type IPD was offset by an increase in disease caused by pneumococcal serotypes not included in the seven-valent vaccine. There were a total of 4,721 projected additional cases of nonvaccine-type IPD across all age groups in 2003.

Routine use of seven-valent pneumococcal conjugate vaccine in young children has dramatically reduced the incidence of vaccine-type and overall invasive pneumococcal disease in children and adults, the Centers for Disease Control and Prevention reported.

The most substantial decline in the rate of vaccine-type disease has been in the target population of children less than 5 years old, according to an analysis comparing disease rates in 2003 with those in 1998–1999, when Prevnar was not available.

In this age group, vaccine-type invasive pneumococcal disease (IPD) decreased 94% from 80 cases per 100,000 population to 4.6 cases (MMWR 2005;54:893–7).

Incidence rates of vaccine-type IPD also declined among individuals outside the target population, with the largest reduction occurring in those 65 years and older.

The routine use of the vaccine prevented 29,599 expected vaccine-type IPD cases in 2003, according to the analysis conducted by the Active Bacterial Core surveillance of the Emerging Infections Program Network in cooperation with the CDC.

An estimated 9,140 cases of vaccine-type IPD were directly prevented by vaccinating children less than 5 years old. An additional 20,459 cases (69%) were prevented through indirect effects of the vaccine across all ages.

Among children less than 5 years old and adults aged 40 years or older, the reduction in vaccine-type IPD was offset by an increase in disease caused by pneumococcal serotypes not included in the seven-valent vaccine. There were a total of 4,721 projected additional cases of nonvaccine-type IPD across all age groups in 2003.

PARIS — Technological advances in lasers and flashlamp devices have given rise to several hair removal myths, including the belief that permanent hair removal requires only a single treatment, that it can be performed on all hair colors and skin types, and that it is without side effects, Christine Dierickx, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

Each laser treatment will temporarily remove all the hair and permanently remove about 20%. A hair-free period of about 1–3 months follows most laser treatments, which is then followed by partial regrowth of about 80% of the hairs.

The percentage of new hairs decreases with each laser treatment because additional permanent hair loss with each laser treatment is about 20%, she said.

Patients typically need five treatments, and they should be warned not to pluck or wax their hair because photothermal energy is absorbed by melanin in the hair shaft.

"Without the target, there is no effect," said Dr. Dierickx, director of the Skin and Laser Center, Brussels.

She was unsuccessful in her attempt to create a target by dying white hair, and has had mixed results with the use of radio frequency energy.

Because melanin in the epidermis presents a competing site for energy absorption, hair removal in patients with Fitzpatrick skin types IV-VI is challenging. Such patients can be safely treated with longer wavelength lasers such as an 800-nm diode or 1,067-nm long-pulsed YAG laser.

However, tanned skin is "merciless," and hair removal should typically be delayed 10–12 weeks after tanning, according to Dr. Dierickx.

Photopneumatic therapy or PPx (Aesthera Corp.) is a new treatment modality that combines light-based hair removal and vacuum suction to lift the skin.

The technology manipulates the optical characteristics of the skin, potentially allowing four to five times more energy to be transmitted to the follicles, Dr. Dierickx said.

Preliminary 3-month results were comparable with conventional 800-nm and 1,064-nm lasers, with 5 of 19 patients achieving 90% hair clearance.

No hair removal system is without risks. Recent reports (J. Am. Acad. Dermatol. 2004;51:774–7) and personal experiences show that livedo reticularis is a new possible side effect of laser-assisted hair removal, she said.

PARIS — Technological advances in lasers and flashlamp devices have given rise to several hair removal myths, including the belief that permanent hair removal requires only a single treatment, that it can be performed on all hair colors and skin types, and that it is without side effects, Christine Dierickx, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

Each laser treatment will temporarily remove all the hair and permanently remove about 20%. A hair-free period of about 1–3 months follows most laser treatments, which is then followed by partial regrowth of about 80% of the hairs.

The percentage of new hairs decreases with each laser treatment because additional permanent hair loss with each laser treatment is about 20%, she said.

Patients typically need five treatments, and they should be warned not to pluck or wax their hair because photothermal energy is absorbed by melanin in the hair shaft.

"Without the target, there is no effect," said Dr. Dierickx, director of the Skin and Laser Center, Brussels.

She was unsuccessful in her attempt to create a target by dying white hair, and has had mixed results with the use of radio frequency energy.

Because melanin in the epidermis presents a competing site for energy absorption, hair removal in patients with Fitzpatrick skin types IV-VI is challenging. Such patients can be safely treated with longer wavelength lasers such as an 800-nm diode or 1,067-nm long-pulsed YAG laser.

However, tanned skin is "merciless," and hair removal should typically be delayed 10–12 weeks after tanning, according to Dr. Dierickx.

Photopneumatic therapy or PPx (Aesthera Corp.) is a new treatment modality that combines light-based hair removal and vacuum suction to lift the skin.

The technology manipulates the optical characteristics of the skin, potentially allowing four to five times more energy to be transmitted to the follicles, Dr. Dierickx said.

Preliminary 3-month results were comparable with conventional 800-nm and 1,064-nm lasers, with 5 of 19 patients achieving 90% hair clearance.

No hair removal system is without risks. Recent reports (J. Am. Acad. Dermatol. 2004;51:774–7) and personal experiences show that livedo reticularis is a new possible side effect of laser-assisted hair removal, she said.

PARIS — Technological advances in lasers and flashlamp devices have given rise to several hair removal myths, including the belief that permanent hair removal requires only a single treatment, that it can be performed on all hair colors and skin types, and that it is without side effects, Christine Dierickx, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

Each laser treatment will temporarily remove all the hair and permanently remove about 20%. A hair-free period of about 1–3 months follows most laser treatments, which is then followed by partial regrowth of about 80% of the hairs.

The percentage of new hairs decreases with each laser treatment because additional permanent hair loss with each laser treatment is about 20%, she said.

Patients typically need five treatments, and they should be warned not to pluck or wax their hair because photothermal energy is absorbed by melanin in the hair shaft.

"Without the target, there is no effect," said Dr. Dierickx, director of the Skin and Laser Center, Brussels.

She was unsuccessful in her attempt to create a target by dying white hair, and has had mixed results with the use of radio frequency energy.

Because melanin in the epidermis presents a competing site for energy absorption, hair removal in patients with Fitzpatrick skin types IV-VI is challenging. Such patients can be safely treated with longer wavelength lasers such as an 800-nm diode or 1,067-nm long-pulsed YAG laser.

However, tanned skin is "merciless," and hair removal should typically be delayed 10–12 weeks after tanning, according to Dr. Dierickx.

Photopneumatic therapy or PPx (Aesthera Corp.) is a new treatment modality that combines light-based hair removal and vacuum suction to lift the skin.

The technology manipulates the optical characteristics of the skin, potentially allowing four to five times more energy to be transmitted to the follicles, Dr. Dierickx said.

Preliminary 3-month results were comparable with conventional 800-nm and 1,064-nm lasers, with 5 of 19 patients achieving 90% hair clearance.

No hair removal system is without risks. Recent reports (J. Am. Acad. Dermatol. 2004;51:774–7) and personal experiences show that livedo reticularis is a new possible side effect of laser-assisted hair removal, she said.

As the number of children taking to the links has steadily risen, so too has the number of pediatric golf-related head injuries.

Golf-related accidents were the second most common cause of sports injury, after bicycle use, among 2,546 patients younger than 19 years who were evaluated by neurosurgeons for any cause at the Medical College of Georgia in Augusta between 1996 and 2002.

A chart review revealed 64 sports injuries, 15 (23%) of which were golf related, according to Scott Y. Rahimi, M.D., lead author and neurosurgery resident at the medical college.

Seven of the golf injuries were caused by golf cart accidents, seven by golf clubs, and one by a golf ball (J. Neurosurg. [Pediatrics 2] 2005;102:163–6).

The mean age of the children in the study was 7 years, and the youngest was 9 months.

The most common injury was depressed skull fracture, which occurred in 7 (47%) of the 15 cases, followed by nondisplaced skull fracture in 3 (20%), subarachnoid hemorrhage in 2 (13%), epidural hematoma in 2 (13%), and subdural hematoma in 1 (6%), Dr. Rahimi reported.

Six children underwent neurosurgical procedures to treat their injuries. Twelve patients made a full recovery, including nine patients who were managed conservatively.

One child developed chronic headaches after a 3-year follow-up.

Another child required permanent shunt placement and underwent multiple shunt revisions because of device malfunction. One child died due to uncontrollable cerebral edema following a golf-cart accident.

A review of the literature by the investigators found that not only are golf-related injuries increasing, but they are the leading type of sports injury in regions where golf is popular, Dr. Rahimi and his colleagues wrote. For examplet, Augusta, Ga., where this research was conducted, is home of the Masters Golf Tournament and a hotbed of golf enthusiasm.

The authors cite a 1997 review of head injuries at the Westchester Medical Center in New York in the 3-month period following Tiger Woods' first Masters championship. The review showed that of the eight children who required surgery for their head injury, half had a depressed skull fracture from a golf club. No similar golf injuries were seen in the 12 months prior to Mr. Woods' win (Surg. Neurol. 1998;50:608).

A report by the Consumer Product Safety Commission identified 19 deaths between 1973 and 1996 that were a direct consequence of children playing with golf clubs (Percept. Mot. Skills 1998;86:747–53).

Golf-related injuries most often involve golf clubs and balls and occur at parks and homes, rather than at golf courses.

Still, the author noted, the growing use of golf carts also has contributed to the increase in accidents.

As a way to prevent or reduce injuries, Dr. Rahimi and his colleagues recommended precautionary guidelines and safety training programs, proper storage of golf clubs, adult supervision of golf-club and golf-cart use, and the requirement of a minimum legal age to drive a golf cart.

In Georgia and many other states, it is illegal to drive a golf cart without a valid driver's license.

At left, a CT scan shows a depressed skull fracture from a golf-related injury. On the right, a scan shows such a fracture repaired with titanium screws and plates. Photos courtesy Dr. Scott Y. Rahimi

As the number of children taking to the links has steadily risen, so too has the number of pediatric golf-related head injuries.

Golf-related accidents were the second most common cause of sports injury, after bicycle use, among 2,546 patients younger than 19 years who were evaluated by neurosurgeons for any cause at the Medical College of Georgia in Augusta between 1996 and 2002.

A chart review revealed 64 sports injuries, 15 (23%) of which were golf related, according to Scott Y. Rahimi, M.D., lead author and neurosurgery resident at the medical college.

Seven of the golf injuries were caused by golf cart accidents, seven by golf clubs, and one by a golf ball (J. Neurosurg. [Pediatrics 2] 2005;102:163–6).

The mean age of the children in the study was 7 years, and the youngest was 9 months.

The most common injury was depressed skull fracture, which occurred in 7 (47%) of the 15 cases, followed by nondisplaced skull fracture in 3 (20%), subarachnoid hemorrhage in 2 (13%), epidural hematoma in 2 (13%), and subdural hematoma in 1 (6%), Dr. Rahimi reported.

Six children underwent neurosurgical procedures to treat their injuries. Twelve patients made a full recovery, including nine patients who were managed conservatively.

One child developed chronic headaches after a 3-year follow-up.

Another child required permanent shunt placement and underwent multiple shunt revisions because of device malfunction. One child died due to uncontrollable cerebral edema following a golf-cart accident.

A review of the literature by the investigators found that not only are golf-related injuries increasing, but they are the leading type of sports injury in regions where golf is popular, Dr. Rahimi and his colleagues wrote. For examplet, Augusta, Ga., where this research was conducted, is home of the Masters Golf Tournament and a hotbed of golf enthusiasm.

The authors cite a 1997 review of head injuries at the Westchester Medical Center in New York in the 3-month period following Tiger Woods' first Masters championship. The review showed that of the eight children who required surgery for their head injury, half had a depressed skull fracture from a golf club. No similar golf injuries were seen in the 12 months prior to Mr. Woods' win (Surg. Neurol. 1998;50:608).

A report by the Consumer Product Safety Commission identified 19 deaths between 1973 and 1996 that were a direct consequence of children playing with golf clubs (Percept. Mot. Skills 1998;86:747–53).

Golf-related injuries most often involve golf clubs and balls and occur at parks and homes, rather than at golf courses.

Still, the author noted, the growing use of golf carts also has contributed to the increase in accidents.

As a way to prevent or reduce injuries, Dr. Rahimi and his colleagues recommended precautionary guidelines and safety training programs, proper storage of golf clubs, adult supervision of golf-club and golf-cart use, and the requirement of a minimum legal age to drive a golf cart.

In Georgia and many other states, it is illegal to drive a golf cart without a valid driver's license.

At left, a CT scan shows a depressed skull fracture from a golf-related injury. On the right, a scan shows such a fracture repaired with titanium screws and plates. Photos courtesy Dr. Scott Y. Rahimi

As the number of children taking to the links has steadily risen, so too has the number of pediatric golf-related head injuries.

Golf-related accidents were the second most common cause of sports injury, after bicycle use, among 2,546 patients younger than 19 years who were evaluated by neurosurgeons for any cause at the Medical College of Georgia in Augusta between 1996 and 2002.

A chart review revealed 64 sports injuries, 15 (23%) of which were golf related, according to Scott Y. Rahimi, M.D., lead author and neurosurgery resident at the medical college.

Seven of the golf injuries were caused by golf cart accidents, seven by golf clubs, and one by a golf ball (J. Neurosurg. [Pediatrics 2] 2005;102:163–6).

The mean age of the children in the study was 7 years, and the youngest was 9 months.

The most common injury was depressed skull fracture, which occurred in 7 (47%) of the 15 cases, followed by nondisplaced skull fracture in 3 (20%), subarachnoid hemorrhage in 2 (13%), epidural hematoma in 2 (13%), and subdural hematoma in 1 (6%), Dr. Rahimi reported.

Six children underwent neurosurgical procedures to treat their injuries. Twelve patients made a full recovery, including nine patients who were managed conservatively.

One child developed chronic headaches after a 3-year follow-up.

Another child required permanent shunt placement and underwent multiple shunt revisions because of device malfunction. One child died due to uncontrollable cerebral edema following a golf-cart accident.

A review of the literature by the investigators found that not only are golf-related injuries increasing, but they are the leading type of sports injury in regions where golf is popular, Dr. Rahimi and his colleagues wrote. For examplet, Augusta, Ga., where this research was conducted, is home of the Masters Golf Tournament and a hotbed of golf enthusiasm.

The authors cite a 1997 review of head injuries at the Westchester Medical Center in New York in the 3-month period following Tiger Woods' first Masters championship. The review showed that of the eight children who required surgery for their head injury, half had a depressed skull fracture from a golf club. No similar golf injuries were seen in the 12 months prior to Mr. Woods' win (Surg. Neurol. 1998;50:608).

A report by the Consumer Product Safety Commission identified 19 deaths between 1973 and 1996 that were a direct consequence of children playing with golf clubs (Percept. Mot. Skills 1998;86:747–53).

Golf-related injuries most often involve golf clubs and balls and occur at parks and homes, rather than at golf courses.

Still, the author noted, the growing use of golf carts also has contributed to the increase in accidents.

As a way to prevent or reduce injuries, Dr. Rahimi and his colleagues recommended precautionary guidelines and safety training programs, proper storage of golf clubs, adult supervision of golf-club and golf-cart use, and the requirement of a minimum legal age to drive a golf cart.

In Georgia and many other states, it is illegal to drive a golf cart without a valid driver's license.

At left, a CT scan shows a depressed skull fracture from a golf-related injury. On the right, a scan shows such a fracture repaired with titanium screws and plates. Photos courtesy Dr. Scott Y. Rahimi

CHICAGO — The morphology and distribution of purpura can help to narrow a differential diagnosis, Warren W. Piette, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

Purpura is the result of one of three hemorrhagic mechanisms: simple, inflammatory, and occlusive. Purpura distribution further focuses the diagnosis, particularly for inflammatory hemorrhage.

“I'd like to resurrect a portion of our skills [of visual diagnosis] … and meld them with the new technologies,” said Dr. Piette, a dermatologist at the John H. Stroger, Jr., Hospital of Cook County in Chicago.

Simple hemorrhages at sites of minor trauma are among the most common causes of purpura. These lesions tend to be nonpalpable, ecchymotic, and nonblanching, with a linear or geometric morphology. Underlying conditions include problems with platelet function, the coagulation cascade, or poor dermal support typically resulting from chronic corticosteroid use or sun damage.

Petechial purpura, measuring 4 mm or less, also results from simple hemorrhage. These are macular and nonblanchable, and typically are associated with a platelet count of 10,000/mm

Inflammatory hemorrhage, in contrast, is associated with palpable purpura that is more problematic to diagnose. Such lesions are typically erythematous and may or may not be vasculitic. Conditions resulting in inflammatory hemorrhage include leukocytoclastic or necrotizing vasculitis, although a few nonvasculitic conditions can be associated with palpable purpura and include chronic pigmented purpura, pityriasis lichenoides et varioliformis acuta (PLEVA), lymphomatoid papulosis, and erythema multiforme.

Vasculitic purpura can be differentiated, based on morphology, as purpura triggered by immune complexes and purpura resulting from pauci-immune mechanisms, he said. Immune complex vasculitis usually has a largely dependent distribution, and the pauci-immune variety has a random distribution.

In vasculitic purpura, it's important to determine the variety of immune complex vasculitis, because IgA-associated vasculitis is more likely than IgG- or IgM-predominant vasculitis to persist, recur, ulcerate, and be associated with systemic disease, he said. Three varieties of renal disease—two of which can lead to renal failure—are associated with IgA vasculitis.

There are eight major categories of occlusive or ischemic hemorrhages and up to 50 possible differential diagnoses associated with them. The most important of the major categories are the cutaneous disseminated coagulopathies, he said.

Dr. Piette illustrated the importance of purpura morphology in diagnosis by describing three patients. All were septic and hypertensive, with evidence of disseminated intravascular coagulation. All had similar platelet values and partial thromboplastin times. One patient presented with petechiae, one with simple ecchymoses, and one with noninflammatory retiform purpura.

In three identical clinical scenarios with variable morphology, “the patient's telling us, 'don't look at my lab [values], look at my skin,'” he said.

The first patient's lesions were petechial size, but were palpable and partially blanchable. Palpable purpura with blanching negates the diagnosis of simple petechiae, and implicates inflammatory hemorrhage. The patient proved to have septic vasculitis associated with meningococcal disease. The diagnosis was confirmed with findings on biopsy of leukocytoclastic vasculitis and spotty fibrin deposition.

The second patient had simple hemorrhage with ecchymotic-sized purpura. The differential diagnosis needed to consider a range of platelet problems, including disseminated intravascular coagulation and multiple cascade coagulation abnormalities. In this case, purpura was the result of a bleeding disorder from a clotting factor abnormality or fibrinogen consumption below critical levels.

The last patient had noninflammatory retiform purpura as a result of occlusion. Laboratory or histologic confirmation can take hours to days in such patients, he said, while the diagnosis can be strongly suggested by the morphology of the lesion and the clinical setting.

CHICAGO — The morphology and distribution of purpura can help to narrow a differential diagnosis, Warren W. Piette, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

Purpura is the result of one of three hemorrhagic mechanisms: simple, inflammatory, and occlusive. Purpura distribution further focuses the diagnosis, particularly for inflammatory hemorrhage.

“I'd like to resurrect a portion of our skills [of visual diagnosis] … and meld them with the new technologies,” said Dr. Piette, a dermatologist at the John H. Stroger, Jr., Hospital of Cook County in Chicago.

Simple hemorrhages at sites of minor trauma are among the most common causes of purpura. These lesions tend to be nonpalpable, ecchymotic, and nonblanching, with a linear or geometric morphology. Underlying conditions include problems with platelet function, the coagulation cascade, or poor dermal support typically resulting from chronic corticosteroid use or sun damage.

Petechial purpura, measuring 4 mm or less, also results from simple hemorrhage. These are macular and nonblanchable, and typically are associated with a platelet count of 10,000/mm

Inflammatory hemorrhage, in contrast, is associated with palpable purpura that is more problematic to diagnose. Such lesions are typically erythematous and may or may not be vasculitic. Conditions resulting in inflammatory hemorrhage include leukocytoclastic or necrotizing vasculitis, although a few nonvasculitic conditions can be associated with palpable purpura and include chronic pigmented purpura, pityriasis lichenoides et varioliformis acuta (PLEVA), lymphomatoid papulosis, and erythema multiforme.

Vasculitic purpura can be differentiated, based on morphology, as purpura triggered by immune complexes and purpura resulting from pauci-immune mechanisms, he said. Immune complex vasculitis usually has a largely dependent distribution, and the pauci-immune variety has a random distribution.

In vasculitic purpura, it's important to determine the variety of immune complex vasculitis, because IgA-associated vasculitis is more likely than IgG- or IgM-predominant vasculitis to persist, recur, ulcerate, and be associated with systemic disease, he said. Three varieties of renal disease—two of which can lead to renal failure—are associated with IgA vasculitis.

There are eight major categories of occlusive or ischemic hemorrhages and up to 50 possible differential diagnoses associated with them. The most important of the major categories are the cutaneous disseminated coagulopathies, he said.

Dr. Piette illustrated the importance of purpura morphology in diagnosis by describing three patients. All were septic and hypertensive, with evidence of disseminated intravascular coagulation. All had similar platelet values and partial thromboplastin times. One patient presented with petechiae, one with simple ecchymoses, and one with noninflammatory retiform purpura.

In three identical clinical scenarios with variable morphology, “the patient's telling us, 'don't look at my lab [values], look at my skin,'” he said.

The first patient's lesions were petechial size, but were palpable and partially blanchable. Palpable purpura with blanching negates the diagnosis of simple petechiae, and implicates inflammatory hemorrhage. The patient proved to have septic vasculitis associated with meningococcal disease. The diagnosis was confirmed with findings on biopsy of leukocytoclastic vasculitis and spotty fibrin deposition.

The second patient had simple hemorrhage with ecchymotic-sized purpura. The differential diagnosis needed to consider a range of platelet problems, including disseminated intravascular coagulation and multiple cascade coagulation abnormalities. In this case, purpura was the result of a bleeding disorder from a clotting factor abnormality or fibrinogen consumption below critical levels.

The last patient had noninflammatory retiform purpura as a result of occlusion. Laboratory or histologic confirmation can take hours to days in such patients, he said, while the diagnosis can be strongly suggested by the morphology of the lesion and the clinical setting.

CHICAGO — The morphology and distribution of purpura can help to narrow a differential diagnosis, Warren W. Piette, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

Purpura is the result of one of three hemorrhagic mechanisms: simple, inflammatory, and occlusive. Purpura distribution further focuses the diagnosis, particularly for inflammatory hemorrhage.

“I'd like to resurrect a portion of our skills [of visual diagnosis] … and meld them with the new technologies,” said Dr. Piette, a dermatologist at the John H. Stroger, Jr., Hospital of Cook County in Chicago.

Simple hemorrhages at sites of minor trauma are among the most common causes of purpura. These lesions tend to be nonpalpable, ecchymotic, and nonblanching, with a linear or geometric morphology. Underlying conditions include problems with platelet function, the coagulation cascade, or poor dermal support typically resulting from chronic corticosteroid use or sun damage.

Petechial purpura, measuring 4 mm or less, also results from simple hemorrhage. These are macular and nonblanchable, and typically are associated with a platelet count of 10,000/mm

Inflammatory hemorrhage, in contrast, is associated with palpable purpura that is more problematic to diagnose. Such lesions are typically erythematous and may or may not be vasculitic. Conditions resulting in inflammatory hemorrhage include leukocytoclastic or necrotizing vasculitis, although a few nonvasculitic conditions can be associated with palpable purpura and include chronic pigmented purpura, pityriasis lichenoides et varioliformis acuta (PLEVA), lymphomatoid papulosis, and erythema multiforme.

Vasculitic purpura can be differentiated, based on morphology, as purpura triggered by immune complexes and purpura resulting from pauci-immune mechanisms, he said. Immune complex vasculitis usually has a largely dependent distribution, and the pauci-immune variety has a random distribution.

In vasculitic purpura, it's important to determine the variety of immune complex vasculitis, because IgA-associated vasculitis is more likely than IgG- or IgM-predominant vasculitis to persist, recur, ulcerate, and be associated with systemic disease, he said. Three varieties of renal disease—two of which can lead to renal failure—are associated with IgA vasculitis.

There are eight major categories of occlusive or ischemic hemorrhages and up to 50 possible differential diagnoses associated with them. The most important of the major categories are the cutaneous disseminated coagulopathies, he said.

Dr. Piette illustrated the importance of purpura morphology in diagnosis by describing three patients. All were septic and hypertensive, with evidence of disseminated intravascular coagulation. All had similar platelet values and partial thromboplastin times. One patient presented with petechiae, one with simple ecchymoses, and one with noninflammatory retiform purpura.

In three identical clinical scenarios with variable morphology, “the patient's telling us, 'don't look at my lab [values], look at my skin,'” he said.

The first patient's lesions were petechial size, but were palpable and partially blanchable. Palpable purpura with blanching negates the diagnosis of simple petechiae, and implicates inflammatory hemorrhage. The patient proved to have septic vasculitis associated with meningococcal disease. The diagnosis was confirmed with findings on biopsy of leukocytoclastic vasculitis and spotty fibrin deposition.

The second patient had simple hemorrhage with ecchymotic-sized purpura. The differential diagnosis needed to consider a range of platelet problems, including disseminated intravascular coagulation and multiple cascade coagulation abnormalities. In this case, purpura was the result of a bleeding disorder from a clotting factor abnormality or fibrinogen consumption below critical levels.

The last patient had noninflammatory retiform purpura as a result of occlusion. Laboratory or histologic confirmation can take hours to days in such patients, he said, while the diagnosis can be strongly suggested by the morphology of the lesion and the clinical setting.

VIENNA — Imatinib, a protein-tyrosine kinase inhibitor indicated for chronic myeloid leukemia and certain stages of gastrointestinal stromal tumors, has shown clinical activity against dermatofibrosarcoma protuberans, Jens Gille, M.D., reported at the 10th World Congress on Cancers of the Skin.

DFSP, a rare and locally aggressive cutaneous tumor, is typically treated with wide surgical excision. Imatinib (Gleevec) could be used to improve the effectiveness of surgery or as an alternative treatment for unresectable DFSP, said Dr. Gille of Johann Wolfgang Goethe University in Frankfurt, Germany.

In a study of 10 people with DFSP, imatinib 400 mg twice daily resulted in a complete clinical response in four patients with locally advanced disease and a partial response in four patients with local disease and in one with metastatic disease (J. Clin. Oncol. 2005;23:866–73).

DFSP is often associated with a translocation between chromosomes 17 and 22. No clinical response was seen in one patient with metastatic disease whose tumor lacked this translocation, suggesting that variants of DFSP without the translocation may not respond to imatinib.

Imatinib, other tyrosine kinase inhibitors, and T4 endonuclease V are among the promising therapeutic avenues being pursued for nonmelanoma skin cancer. The epidermal growth factor receptor tyrosine kinase inhibitors, gefitinib (Iressa) and erlotinib (Tarceva), are approved for advanced non-small cell lung cancers, and have potential for squamous cell carcinomas of the skin, he said.

Two phase II trials of gefitinib are underway in patients with squamous cell carcinoma and topical therapies on the horizon include T4 endonuclease V, a bacterial DNA repair enzyme that increases the rate of repair of sunlight-induced DNA damage in human cells, Dr. Gille said at the congress cosponsored by the Skin Cancer Foundation.

Dr. Gille also noted that the effectiveness of cyclooxygenase-2 inhibitors in nonmelanoma skin cancer remains to be determined. Two skin trials were halted in 2005 after concerns were raised about the safety of several COX-2 inhibitors.

The trials were evaluating the effectiveness of celecoxib (Celebrex) in 60 patients with basal cell nevi and in 240 patients with sun-damaged skin. Analyses of the available data from both trials could be out later this year, he said.

VIENNA — Imatinib, a protein-tyrosine kinase inhibitor indicated for chronic myeloid leukemia and certain stages of gastrointestinal stromal tumors, has shown clinical activity against dermatofibrosarcoma protuberans, Jens Gille, M.D., reported at the 10th World Congress on Cancers of the Skin.

DFSP, a rare and locally aggressive cutaneous tumor, is typically treated with wide surgical excision. Imatinib (Gleevec) could be used to improve the effectiveness of surgery or as an alternative treatment for unresectable DFSP, said Dr. Gille of Johann Wolfgang Goethe University in Frankfurt, Germany.

In a study of 10 people with DFSP, imatinib 400 mg twice daily resulted in a complete clinical response in four patients with locally advanced disease and a partial response in four patients with local disease and in one with metastatic disease (J. Clin. Oncol. 2005;23:866–73).

DFSP is often associated with a translocation between chromosomes 17 and 22. No clinical response was seen in one patient with metastatic disease whose tumor lacked this translocation, suggesting that variants of DFSP without the translocation may not respond to imatinib.

Imatinib, other tyrosine kinase inhibitors, and T4 endonuclease V are among the promising therapeutic avenues being pursued for nonmelanoma skin cancer. The epidermal growth factor receptor tyrosine kinase inhibitors, gefitinib (Iressa) and erlotinib (Tarceva), are approved for advanced non-small cell lung cancers, and have potential for squamous cell carcinomas of the skin, he said.

Two phase II trials of gefitinib are underway in patients with squamous cell carcinoma and topical therapies on the horizon include T4 endonuclease V, a bacterial DNA repair enzyme that increases the rate of repair of sunlight-induced DNA damage in human cells, Dr. Gille said at the congress cosponsored by the Skin Cancer Foundation.

Dr. Gille also noted that the effectiveness of cyclooxygenase-2 inhibitors in nonmelanoma skin cancer remains to be determined. Two skin trials were halted in 2005 after concerns were raised about the safety of several COX-2 inhibitors.

The trials were evaluating the effectiveness of celecoxib (Celebrex) in 60 patients with basal cell nevi and in 240 patients with sun-damaged skin. Analyses of the available data from both trials could be out later this year, he said.

VIENNA — Imatinib, a protein-tyrosine kinase inhibitor indicated for chronic myeloid leukemia and certain stages of gastrointestinal stromal tumors, has shown clinical activity against dermatofibrosarcoma protuberans, Jens Gille, M.D., reported at the 10th World Congress on Cancers of the Skin.

DFSP, a rare and locally aggressive cutaneous tumor, is typically treated with wide surgical excision. Imatinib (Gleevec) could be used to improve the effectiveness of surgery or as an alternative treatment for unresectable DFSP, said Dr. Gille of Johann Wolfgang Goethe University in Frankfurt, Germany.

In a study of 10 people with DFSP, imatinib 400 mg twice daily resulted in a complete clinical response in four patients with locally advanced disease and a partial response in four patients with local disease and in one with metastatic disease (J. Clin. Oncol. 2005;23:866–73).

DFSP is often associated with a translocation between chromosomes 17 and 22. No clinical response was seen in one patient with metastatic disease whose tumor lacked this translocation, suggesting that variants of DFSP without the translocation may not respond to imatinib.

Imatinib, other tyrosine kinase inhibitors, and T4 endonuclease V are among the promising therapeutic avenues being pursued for nonmelanoma skin cancer. The epidermal growth factor receptor tyrosine kinase inhibitors, gefitinib (Iressa) and erlotinib (Tarceva), are approved for advanced non-small cell lung cancers, and have potential for squamous cell carcinomas of the skin, he said.

Two phase II trials of gefitinib are underway in patients with squamous cell carcinoma and topical therapies on the horizon include T4 endonuclease V, a bacterial DNA repair enzyme that increases the rate of repair of sunlight-induced DNA damage in human cells, Dr. Gille said at the congress cosponsored by the Skin Cancer Foundation.

Dr. Gille also noted that the effectiveness of cyclooxygenase-2 inhibitors in nonmelanoma skin cancer remains to be determined. Two skin trials were halted in 2005 after concerns were raised about the safety of several COX-2 inhibitors.

The trials were evaluating the effectiveness of celecoxib (Celebrex) in 60 patients with basal cell nevi and in 240 patients with sun-damaged skin. Analyses of the available data from both trials could be out later this year, he said.