Betsy Bates

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest to tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus, and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

“I view the tetracyclines as the drugs I would like to save … for the future,” Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, said Dr. Baldwin of the State University of New York, Brooklyn.

“The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it,” she said.

Her strategy has been to “utilize antibiotics when necessary, but devise an exit strategy on day 1.”

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessarily act quickly.

By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued. “On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide,” she advised. Even though it is bactericidal, no resistance develops in response to benzoyl peroxide, she said.

“What I don't think people worry about are topical antibiotics,” she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence arrived in 2003 with a disturbing study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467–71).

Another study looked retrospectively at the charts of 118,496 patients, finding that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132–6).

“The issue is bigger than [Propionibacterium]acnes resistance or upper respiratory infections,” Dr. Baldwin said. “The whole thing ends up being a story of more severe organisms and MRSA.”

Community-acquired MRSA is increasingly familiar to dermatologists, since it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist; pain is more severe than the clinical appearance of lesions might suggest.

“The treatment is drainage, drainage, drainage,” she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, “tetracyclines are probably the easiest drugs that we have to treat it,” she said. (See box.)

“Do we overprescribe antibiotics? Of course we do,” Dr. Baldwin said. Dermatologists write 8–9 million prescriptions a year for antibiotics and 40%–50% of all prescriptions for tetracyclines.

The reasons are many: not wanting to miss infections, avoiding medicolegal problems, and basically just wanting a quick response to inflammatory conditions such as acne and rosacea. “Sometimes patients just wear us the heck down,” she admitted.

Dr. Baldwin disclosed ties with several pharmaceutical companies.

'Antibiotic resistance is here, it's now, and we have to worry about it.' DR. BALDWIN

Current Antibiotic Choices for MRSA

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective against MRSA.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones (ciprofloxacin, levofloxacin, etc.): Promote emergence of MRSA.

Lincosamides (clindamycin): Covers some MRSA, but resistance is growing.

Glycopeptides (vancomycin): Resistance is increasing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones (linezolid, etc.): Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but effective for skin/soft tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer Inc. withdrew the application for this injectable.

Telavancin: The application for this injectable was suspended.

Ceftobiprole: The application for this new cephalosporin was suspended.

Oral antibiotics in development for MRSA: None.

Sources: Dr. Baldwin, Dr. Paul Holtom

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest to tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus, and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

“I view the tetracyclines as the drugs I would like to save … for the future,” Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, said Dr. Baldwin of the State University of New York, Brooklyn.

“The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it,” she said.

Her strategy has been to “utilize antibiotics when necessary, but devise an exit strategy on day 1.”

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessarily act quickly.

By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued. “On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide,” she advised. Even though it is bactericidal, no resistance develops in response to benzoyl peroxide, she said.

“What I don't think people worry about are topical antibiotics,” she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence arrived in 2003 with a disturbing study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467–71).

Another study looked retrospectively at the charts of 118,496 patients, finding that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132–6).

“The issue is bigger than [Propionibacterium]acnes resistance or upper respiratory infections,” Dr. Baldwin said. “The whole thing ends up being a story of more severe organisms and MRSA.”

Community-acquired MRSA is increasingly familiar to dermatologists, since it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist; pain is more severe than the clinical appearance of lesions might suggest.

“The treatment is drainage, drainage, drainage,” she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, “tetracyclines are probably the easiest drugs that we have to treat it,” she said. (See box.)

“Do we overprescribe antibiotics? Of course we do,” Dr. Baldwin said. Dermatologists write 8–9 million prescriptions a year for antibiotics and 40%–50% of all prescriptions for tetracyclines.

The reasons are many: not wanting to miss infections, avoiding medicolegal problems, and basically just wanting a quick response to inflammatory conditions such as acne and rosacea. “Sometimes patients just wear us the heck down,” she admitted.

Dr. Baldwin disclosed ties with several pharmaceutical companies.

'Antibiotic resistance is here, it's now, and we have to worry about it.' DR. BALDWIN

Current Antibiotic Choices for MRSA

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective against MRSA.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones (ciprofloxacin, levofloxacin, etc.): Promote emergence of MRSA.

Lincosamides (clindamycin): Covers some MRSA, but resistance is growing.

Glycopeptides (vancomycin): Resistance is increasing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones (linezolid, etc.): Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but effective for skin/soft tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer Inc. withdrew the application for this injectable.

Telavancin: The application for this injectable was suspended.

Ceftobiprole: The application for this new cephalosporin was suspended.

Oral antibiotics in development for MRSA: None.

Sources: Dr. Baldwin, Dr. Paul Holtom

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest to tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus, and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

“I view the tetracyclines as the drugs I would like to save … for the future,” Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, said Dr. Baldwin of the State University of New York, Brooklyn.

“The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it,” she said.

Her strategy has been to “utilize antibiotics when necessary, but devise an exit strategy on day 1.”

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessarily act quickly.

By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued. “On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide,” she advised. Even though it is bactericidal, no resistance develops in response to benzoyl peroxide, she said.

“What I don't think people worry about are topical antibiotics,” she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence arrived in 2003 with a disturbing study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467–71).

Another study looked retrospectively at the charts of 118,496 patients, finding that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132–6).

“The issue is bigger than [Propionibacterium]acnes resistance or upper respiratory infections,” Dr. Baldwin said. “The whole thing ends up being a story of more severe organisms and MRSA.”

Community-acquired MRSA is increasingly familiar to dermatologists, since it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist; pain is more severe than the clinical appearance of lesions might suggest.

“The treatment is drainage, drainage, drainage,” she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, “tetracyclines are probably the easiest drugs that we have to treat it,” she said. (See box.)

“Do we overprescribe antibiotics? Of course we do,” Dr. Baldwin said. Dermatologists write 8–9 million prescriptions a year for antibiotics and 40%–50% of all prescriptions for tetracyclines.

The reasons are many: not wanting to miss infections, avoiding medicolegal problems, and basically just wanting a quick response to inflammatory conditions such as acne and rosacea. “Sometimes patients just wear us the heck down,” she admitted.

Dr. Baldwin disclosed ties with several pharmaceutical companies.

'Antibiotic resistance is here, it's now, and we have to worry about it.' DR. BALDWIN

Current Antibiotic Choices for MRSA

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective against MRSA.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones (ciprofloxacin, levofloxacin, etc.): Promote emergence of MRSA.

Lincosamides (clindamycin): Covers some MRSA, but resistance is growing.

Glycopeptides (vancomycin): Resistance is increasing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones (linezolid, etc.): Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but effective for skin/soft tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer Inc. withdrew the application for this injectable.

Telavancin: The application for this injectable was suspended.

Ceftobiprole: The application for this new cephalosporin was suspended.

Oral antibiotics in development for MRSA: None.

Sources: Dr. Baldwin, Dr. Paul Holtom

SALT LAKE CITY — A number of novel risk factors—many sharing the common denominator of cholinergic dysfunction—emerged as potential early markers of dementia in Parkinson's disease in a longitudinal study of newly diagnosed patients.

Gastrointestinal, urologic, and cardiac disorders emerged as predictors in the massive DATATOP study, a project of the Parkinson Study Group. The study enrolled and extensively studied 740 newly diagnosed, untreated Parkinson's disease (PD) patients for more than 5 years.

The primary objective of the study was to compare deprenyl with tocopherol in the treatment of early PD, with deprenyl showing short-term benefit (Ann. Neurol. 1998;44:[S]160–6).

However, the large database also permitted examination of other questions, such as the progressive emergence of dementia in a relatively young, early-stage population. The mean age of DATATOP participants at enrollment was 61, and their Hoehn-Yahr Parkinson's disease stage averaged 1–2.5 on the 5-stage scale.

Dr. Ergun Y. Uc of the University of Iowa, Iowa City, reported the results in an oral presentation at the annual meeting of the American Neurological Association.

Dementia symptoms developed in 2.4% of 740 subjects in the first 2 years of follow-up and in 5.8% of subjects in the first 5 years, an incidence rate higher than that seen in the general population, but lower than what is usually seen in Parkinson's populations.

The annual incidence rate for dementia development in the group was 12.7 per 1,000. Baseline predictors of dementia included well-known risk factors such as older age, male gender, and Postural Instability and Gait Disorder (PIGD) score, as well as the predictable signal of lower scores on cognitive psychological tests at enrollment.

Several additional risk factors emerged as well, including gastrointestinal, urologic, and cardiac disorders; increased symmetry of Parkinsonism; and impairment of speech and swallowing (bulbar dysfunction).

Gastrointestinal dysfunction emerged as a surprisingly potent risk factor for dementia at an odds ratio of 2.28, just behind male gender, which had an odds ratio of 2.95. Urologic dysfunction was close behind at an odds ratio of 1.99. Increased symmetry of Parkinsonism conferred an odds ratio of 1.44. PIGD scores, at an odds ratio of 1.13, and total motor score, at 1.03, were less important risk factors in this population than previously believed, Dr. Uc said.

Baseline psychological tests such as total recall, delayed recall, and symbol-digit tests were, not surprisingly, the most important factors in predicting development of dementia, he continued.

“Subjects destined to be demented started out 1 standard deviation below normal,” he said.

Despite practice effects, which would be expected to improve their scores, “by 4 years they dropped off the cliff,” he said.

The average time-to-progression for dementia was 3.3 years after enrollment.

Demented subjects were more likely than other subjects to have a history of falls and gait disturbances, bulbar problems with speech, drooling and swallowing, and functional praxis (difficulties in writing, using utensils, dressing, personal hygiene functions, and turning in bed.)

Dr. Uc suggested that the multifaceted picture of dementia risk points to dysfunction in autonomic cholinergic neurotransmission as a promising target for diagnosis and prevention in patients with early-stage Parkinson's disease.

SALT LAKE CITY — A number of novel risk factors—many sharing the common denominator of cholinergic dysfunction—emerged as potential early markers of dementia in Parkinson's disease in a longitudinal study of newly diagnosed patients.

Gastrointestinal, urologic, and cardiac disorders emerged as predictors in the massive DATATOP study, a project of the Parkinson Study Group. The study enrolled and extensively studied 740 newly diagnosed, untreated Parkinson's disease (PD) patients for more than 5 years.

The primary objective of the study was to compare deprenyl with tocopherol in the treatment of early PD, with deprenyl showing short-term benefit (Ann. Neurol. 1998;44:[S]160–6).

However, the large database also permitted examination of other questions, such as the progressive emergence of dementia in a relatively young, early-stage population. The mean age of DATATOP participants at enrollment was 61, and their Hoehn-Yahr Parkinson's disease stage averaged 1–2.5 on the 5-stage scale.

Dr. Ergun Y. Uc of the University of Iowa, Iowa City, reported the results in an oral presentation at the annual meeting of the American Neurological Association.

Dementia symptoms developed in 2.4% of 740 subjects in the first 2 years of follow-up and in 5.8% of subjects in the first 5 years, an incidence rate higher than that seen in the general population, but lower than what is usually seen in Parkinson's populations.

The annual incidence rate for dementia development in the group was 12.7 per 1,000. Baseline predictors of dementia included well-known risk factors such as older age, male gender, and Postural Instability and Gait Disorder (PIGD) score, as well as the predictable signal of lower scores on cognitive psychological tests at enrollment.

Several additional risk factors emerged as well, including gastrointestinal, urologic, and cardiac disorders; increased symmetry of Parkinsonism; and impairment of speech and swallowing (bulbar dysfunction).

Gastrointestinal dysfunction emerged as a surprisingly potent risk factor for dementia at an odds ratio of 2.28, just behind male gender, which had an odds ratio of 2.95. Urologic dysfunction was close behind at an odds ratio of 1.99. Increased symmetry of Parkinsonism conferred an odds ratio of 1.44. PIGD scores, at an odds ratio of 1.13, and total motor score, at 1.03, were less important risk factors in this population than previously believed, Dr. Uc said.

Baseline psychological tests such as total recall, delayed recall, and symbol-digit tests were, not surprisingly, the most important factors in predicting development of dementia, he continued.

“Subjects destined to be demented started out 1 standard deviation below normal,” he said.

Despite practice effects, which would be expected to improve their scores, “by 4 years they dropped off the cliff,” he said.

The average time-to-progression for dementia was 3.3 years after enrollment.

Demented subjects were more likely than other subjects to have a history of falls and gait disturbances, bulbar problems with speech, drooling and swallowing, and functional praxis (difficulties in writing, using utensils, dressing, personal hygiene functions, and turning in bed.)

Dr. Uc suggested that the multifaceted picture of dementia risk points to dysfunction in autonomic cholinergic neurotransmission as a promising target for diagnosis and prevention in patients with early-stage Parkinson's disease.

SALT LAKE CITY — A number of novel risk factors—many sharing the common denominator of cholinergic dysfunction—emerged as potential early markers of dementia in Parkinson's disease in a longitudinal study of newly diagnosed patients.

Gastrointestinal, urologic, and cardiac disorders emerged as predictors in the massive DATATOP study, a project of the Parkinson Study Group. The study enrolled and extensively studied 740 newly diagnosed, untreated Parkinson's disease (PD) patients for more than 5 years.

The primary objective of the study was to compare deprenyl with tocopherol in the treatment of early PD, with deprenyl showing short-term benefit (Ann. Neurol. 1998;44:[S]160–6).

However, the large database also permitted examination of other questions, such as the progressive emergence of dementia in a relatively young, early-stage population. The mean age of DATATOP participants at enrollment was 61, and their Hoehn-Yahr Parkinson's disease stage averaged 1–2.5 on the 5-stage scale.

Dr. Ergun Y. Uc of the University of Iowa, Iowa City, reported the results in an oral presentation at the annual meeting of the American Neurological Association.

Dementia symptoms developed in 2.4% of 740 subjects in the first 2 years of follow-up and in 5.8% of subjects in the first 5 years, an incidence rate higher than that seen in the general population, but lower than what is usually seen in Parkinson's populations.

The annual incidence rate for dementia development in the group was 12.7 per 1,000. Baseline predictors of dementia included well-known risk factors such as older age, male gender, and Postural Instability and Gait Disorder (PIGD) score, as well as the predictable signal of lower scores on cognitive psychological tests at enrollment.

Several additional risk factors emerged as well, including gastrointestinal, urologic, and cardiac disorders; increased symmetry of Parkinsonism; and impairment of speech and swallowing (bulbar dysfunction).

Gastrointestinal dysfunction emerged as a surprisingly potent risk factor for dementia at an odds ratio of 2.28, just behind male gender, which had an odds ratio of 2.95. Urologic dysfunction was close behind at an odds ratio of 1.99. Increased symmetry of Parkinsonism conferred an odds ratio of 1.44. PIGD scores, at an odds ratio of 1.13, and total motor score, at 1.03, were less important risk factors in this population than previously believed, Dr. Uc said.

Baseline psychological tests such as total recall, delayed recall, and symbol-digit tests were, not surprisingly, the most important factors in predicting development of dementia, he continued.

“Subjects destined to be demented started out 1 standard deviation below normal,” he said.

Despite practice effects, which would be expected to improve their scores, “by 4 years they dropped off the cliff,” he said.

The average time-to-progression for dementia was 3.3 years after enrollment.

Demented subjects were more likely than other subjects to have a history of falls and gait disturbances, bulbar problems with speech, drooling and swallowing, and functional praxis (difficulties in writing, using utensils, dressing, personal hygiene functions, and turning in bed.)

Dr. Uc suggested that the multifaceted picture of dementia risk points to dysfunction in autonomic cholinergic neurotransmission as a promising target for diagnosis and prevention in patients with early-stage Parkinson's disease.

SALT LAKE CITY — Deep brain stimulation surgery proved far more effective than medical therapy in a large, randomized Parkinson's disease trial in the United Kingdom, adding to mounting evidence that surgery is the best option for many patients with advanced disease.

The PD SURG trial randomized 366 patients with advanced disease to receive subthalamic nucleus deep brain stimulation (183 patients) or medical therapy (also 183) at centers located throughout the United Kingdom.

Interim results were reported at the annual meeting of the American Neurological Association by Dr. Adrian Williams, professor of clinical neurology at Queen Elizabeth Hospital, Birmingham (England) and coordinator of the trial.

“For 25%–30% of the patients, there was a very, very significant improvement in quality of life,” he said in an interview at the meeting.

Patients enrolled in the trial had quite extensive disease, with 11 years' mean disease duration. Their main reasons for considering surgery were dyskinesia and severe off-periods, said Dr. Williams.

At 1 year, overall PDQ-39 (Parkinson's Disease Questionnaire) scores were unchanged in patients receiving medication alone, but improved 5.8 points on the 156-point scale in those who received surgery, a highly significant difference (P = .0002).

Within this scale, activities of daily living showed a particularly pronounced improvement in patients who underwent surgery, improving, on average 12 points among surgical patients but less than 1 point among patients receiving medical therapy, Dr. Williams noted.

A similarly significant, 8.5-point difference in scores on the 0- to 176-point Unified Parkinson's Disease Rating Scale (UPDRS) favored patients in the surgical arm.

A subset of patients had a dramatic response to surgery, Dr. Williams said.

Nearly a quarter of patients who underwent surgery showed 16-point or greater reductions in their overall PDQ-39 scores, compared with 2% of patients receiving medical therapy. These patients, he said, “tended to be a bit younger, with slightly more aggressive disease.”

Their motor involvement tended to be profound at the onset of the study.

As in previous studies, some patients failed to show much improvement following surgery, suggesting the need for identifying clear predictive factors that can tailor interventions to those most likely to benefit, Dr. Williams said.

Surgery was not without risks, with 1% of patients dying and 1% suffering strokes in the surgery arm.

The cost of surgery was about double that of a years' worth of drug therapy, but the magnitude of improvement of some patients would certainly justify the cost.

Dr. Williams stressed the “real world” design of the trial, which attempted true randomization at regional centers rather than “cherry picking by patient or by surgeon.” For ethical reasons, patients assigned to the medication arm of the study were offered surgery after 1 year.

The PD SURG trial was supported by the U.K. Medical Research Council and the Parkinson's Disease Society.

The study results parallel findings in two smaller, National Institutes of Health- sponsored trials, one performed with the Department of Veterans Affairs and one coordinated by researchers at the University of Florida, Gainesville.

SALT LAKE CITY — Deep brain stimulation surgery proved far more effective than medical therapy in a large, randomized Parkinson's disease trial in the United Kingdom, adding to mounting evidence that surgery is the best option for many patients with advanced disease.

The PD SURG trial randomized 366 patients with advanced disease to receive subthalamic nucleus deep brain stimulation (183 patients) or medical therapy (also 183) at centers located throughout the United Kingdom.

Interim results were reported at the annual meeting of the American Neurological Association by Dr. Adrian Williams, professor of clinical neurology at Queen Elizabeth Hospital, Birmingham (England) and coordinator of the trial.

“For 25%–30% of the patients, there was a very, very significant improvement in quality of life,” he said in an interview at the meeting.

Patients enrolled in the trial had quite extensive disease, with 11 years' mean disease duration. Their main reasons for considering surgery were dyskinesia and severe off-periods, said Dr. Williams.

At 1 year, overall PDQ-39 (Parkinson's Disease Questionnaire) scores were unchanged in patients receiving medication alone, but improved 5.8 points on the 156-point scale in those who received surgery, a highly significant difference (P = .0002).

Within this scale, activities of daily living showed a particularly pronounced improvement in patients who underwent surgery, improving, on average 12 points among surgical patients but less than 1 point among patients receiving medical therapy, Dr. Williams noted.

A similarly significant, 8.5-point difference in scores on the 0- to 176-point Unified Parkinson's Disease Rating Scale (UPDRS) favored patients in the surgical arm.

A subset of patients had a dramatic response to surgery, Dr. Williams said.

Nearly a quarter of patients who underwent surgery showed 16-point or greater reductions in their overall PDQ-39 scores, compared with 2% of patients receiving medical therapy. These patients, he said, “tended to be a bit younger, with slightly more aggressive disease.”

Their motor involvement tended to be profound at the onset of the study.

As in previous studies, some patients failed to show much improvement following surgery, suggesting the need for identifying clear predictive factors that can tailor interventions to those most likely to benefit, Dr. Williams said.

Surgery was not without risks, with 1% of patients dying and 1% suffering strokes in the surgery arm.

The cost of surgery was about double that of a years' worth of drug therapy, but the magnitude of improvement of some patients would certainly justify the cost.

Dr. Williams stressed the “real world” design of the trial, which attempted true randomization at regional centers rather than “cherry picking by patient or by surgeon.” For ethical reasons, patients assigned to the medication arm of the study were offered surgery after 1 year.

The PD SURG trial was supported by the U.K. Medical Research Council and the Parkinson's Disease Society.

The study results parallel findings in two smaller, National Institutes of Health- sponsored trials, one performed with the Department of Veterans Affairs and one coordinated by researchers at the University of Florida, Gainesville.

SALT LAKE CITY — Deep brain stimulation surgery proved far more effective than medical therapy in a large, randomized Parkinson's disease trial in the United Kingdom, adding to mounting evidence that surgery is the best option for many patients with advanced disease.

The PD SURG trial randomized 366 patients with advanced disease to receive subthalamic nucleus deep brain stimulation (183 patients) or medical therapy (also 183) at centers located throughout the United Kingdom.

Interim results were reported at the annual meeting of the American Neurological Association by Dr. Adrian Williams, professor of clinical neurology at Queen Elizabeth Hospital, Birmingham (England) and coordinator of the trial.

“For 25%–30% of the patients, there was a very, very significant improvement in quality of life,” he said in an interview at the meeting.

Patients enrolled in the trial had quite extensive disease, with 11 years' mean disease duration. Their main reasons for considering surgery were dyskinesia and severe off-periods, said Dr. Williams.

At 1 year, overall PDQ-39 (Parkinson's Disease Questionnaire) scores were unchanged in patients receiving medication alone, but improved 5.8 points on the 156-point scale in those who received surgery, a highly significant difference (P = .0002).

Within this scale, activities of daily living showed a particularly pronounced improvement in patients who underwent surgery, improving, on average 12 points among surgical patients but less than 1 point among patients receiving medical therapy, Dr. Williams noted.

A similarly significant, 8.5-point difference in scores on the 0- to 176-point Unified Parkinson's Disease Rating Scale (UPDRS) favored patients in the surgical arm.

A subset of patients had a dramatic response to surgery, Dr. Williams said.

Nearly a quarter of patients who underwent surgery showed 16-point or greater reductions in their overall PDQ-39 scores, compared with 2% of patients receiving medical therapy. These patients, he said, “tended to be a bit younger, with slightly more aggressive disease.”

Their motor involvement tended to be profound at the onset of the study.

As in previous studies, some patients failed to show much improvement following surgery, suggesting the need for identifying clear predictive factors that can tailor interventions to those most likely to benefit, Dr. Williams said.

Surgery was not without risks, with 1% of patients dying and 1% suffering strokes in the surgery arm.

The cost of surgery was about double that of a years' worth of drug therapy, but the magnitude of improvement of some patients would certainly justify the cost.

Dr. Williams stressed the “real world” design of the trial, which attempted true randomization at regional centers rather than “cherry picking by patient or by surgeon.” For ethical reasons, patients assigned to the medication arm of the study were offered surgery after 1 year.

The PD SURG trial was supported by the U.K. Medical Research Council and the Parkinson's Disease Society.

The study results parallel findings in two smaller, National Institutes of Health- sponsored trials, one performed with the Department of Veterans Affairs and one coordinated by researchers at the University of Florida, Gainesville.

SAN FRANCISCO — Patients with rheumatoid arthritis have a “markedly” lower mean left ventricular mass than do age-matched controls, a finding that provides what may be a significant clue to elevated cardiovascular mortality in this population, according to a group of Maryland researchers.

The specific mechanisms underlying cardiovascular risk are only now being fully explored in this population, in part because RA patients often fail to present with the classic early signs and symptoms of cardiac disease, commented Dr. Jon Giles, who is a rheumatologist at the Johns Hopkins Division of Rheumatology in Baltimore, in a presentation given at the recent annual meeting of the American College of Rheumatology.

For example, Dr. Giles cited heart failure rates that are “nearly doubled” in RA patients.

Yet, “little is known about the myocardial changes that precede clinical heart failure in these patients,” he said.

Dr. Giles and his associates turned to cardiac MRI, a highly sensitive tool for assessing left ventricular structure and function, to hunt for preclinical risk factors for heart failure.

Rheumatoid arthritis patients with moderate disease (average 7 years' duration) who enrolled in the ESCAPE RA trial (n = 75) were compared with 775 participants in the Multi-Ethnic Study of Atherosclerosis who did not have RA. None of the members of either group had a history of cardiovascular events or procedures.

The rheumatoid arthritis cohort was younger than was the control group (mean age 59, compared with 63), and was also less likely to have a diagnosis of diabetes (4% versus 14%) or hypertension (32% versus 49%).

However, the patients' mean unadjusted left ventricular mass was 18% lower (120 g/m

The difference was particularly pronounced for male patients with RA, whose mean adjusted left ventricular mass was found to be fully 19% lower than that of men who did not have a rheumatoid arthritis diagnosis.

Female rheumatoid arthritis patients had a 9% lower left ventricular mass than did women without the inflammatory disease.

In both the RA and control groups, mean left ventricular mass decreased with age.

However, it was lower in rheumatoid arthritis patients than in controls in every age group, including the youngest patients in the study.

“In fact, the mean left ventricular mass was lower in 45-year-old RA patients than mean left ventricular mass in 80-year-old control patients, regardless of gender,” Dr. Giles commented during his podium presentation.

Left ventricular stroke volume was marginally lower in RA patients than in controls, significantly so in men.

“Small but significant” reductions in adjusted mean ejection fraction were seen as well, Dr. Giles said.

No differences were seen in RA patients and controls with regard to adjusted mean end diastolic volume.

The Johns Hopkins team also explored potentially significant associations between cardiovascular risk markers and RA disease characteristics such as disease severity, activity, treatment, and systemic inflammation.

They found only two factors that were independently associated with left ventricular mass, stroke volume, and end diastolic volume in rheumatoid arthritis patients.

One factor was increased anti-cyclic citrullinated peptide antibodies.

The other was the use of biological disease-modifying drugs (predominantly tumor necrosis factor-α inhibitors).

No characteristics were associated with ejection fraction.

The study findings raise intriguing questions about whether rheumatoid arthritis and its treatment heighten patients' cardiovascular risk through different mechanisms than in the general, non-RA population, said Dr. Giles.

For example, markedly lower left ventricular mass may reflect the “aftereffects” of subclinical myocarditis.

On the other hand, lower left ventricular mass measurements “may support the concept that RA is a disorder of accelerated aging,” he said.

Dr. Giles and his associates reported having no financial conflicts of interest with regard to this study.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Patients with rheumatoid arthritis have a “markedly” lower mean left ventricular mass than do age-matched controls, a finding that provides what may be a significant clue to elevated cardiovascular mortality in this population, according to a group of Maryland researchers.

The specific mechanisms underlying cardiovascular risk are only now being fully explored in this population, in part because RA patients often fail to present with the classic early signs and symptoms of cardiac disease, commented Dr. Jon Giles, who is a rheumatologist at the Johns Hopkins Division of Rheumatology in Baltimore, in a presentation given at the recent annual meeting of the American College of Rheumatology.

For example, Dr. Giles cited heart failure rates that are “nearly doubled” in RA patients.

Yet, “little is known about the myocardial changes that precede clinical heart failure in these patients,” he said.

Dr. Giles and his associates turned to cardiac MRI, a highly sensitive tool for assessing left ventricular structure and function, to hunt for preclinical risk factors for heart failure.

Rheumatoid arthritis patients with moderate disease (average 7 years' duration) who enrolled in the ESCAPE RA trial (n = 75) were compared with 775 participants in the Multi-Ethnic Study of Atherosclerosis who did not have RA. None of the members of either group had a history of cardiovascular events or procedures.

The rheumatoid arthritis cohort was younger than was the control group (mean age 59, compared with 63), and was also less likely to have a diagnosis of diabetes (4% versus 14%) or hypertension (32% versus 49%).

However, the patients' mean unadjusted left ventricular mass was 18% lower (120 g/m

The difference was particularly pronounced for male patients with RA, whose mean adjusted left ventricular mass was found to be fully 19% lower than that of men who did not have a rheumatoid arthritis diagnosis.

Female rheumatoid arthritis patients had a 9% lower left ventricular mass than did women without the inflammatory disease.

In both the RA and control groups, mean left ventricular mass decreased with age.

However, it was lower in rheumatoid arthritis patients than in controls in every age group, including the youngest patients in the study.

“In fact, the mean left ventricular mass was lower in 45-year-old RA patients than mean left ventricular mass in 80-year-old control patients, regardless of gender,” Dr. Giles commented during his podium presentation.

Left ventricular stroke volume was marginally lower in RA patients than in controls, significantly so in men.

“Small but significant” reductions in adjusted mean ejection fraction were seen as well, Dr. Giles said.

No differences were seen in RA patients and controls with regard to adjusted mean end diastolic volume.

The Johns Hopkins team also explored potentially significant associations between cardiovascular risk markers and RA disease characteristics such as disease severity, activity, treatment, and systemic inflammation.

They found only two factors that were independently associated with left ventricular mass, stroke volume, and end diastolic volume in rheumatoid arthritis patients.

One factor was increased anti-cyclic citrullinated peptide antibodies.

The other was the use of biological disease-modifying drugs (predominantly tumor necrosis factor-α inhibitors).

No characteristics were associated with ejection fraction.

The study findings raise intriguing questions about whether rheumatoid arthritis and its treatment heighten patients' cardiovascular risk through different mechanisms than in the general, non-RA population, said Dr. Giles.

For example, markedly lower left ventricular mass may reflect the “aftereffects” of subclinical myocarditis.

On the other hand, lower left ventricular mass measurements “may support the concept that RA is a disorder of accelerated aging,” he said.

Dr. Giles and his associates reported having no financial conflicts of interest with regard to this study.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Patients with rheumatoid arthritis have a “markedly” lower mean left ventricular mass than do age-matched controls, a finding that provides what may be a significant clue to elevated cardiovascular mortality in this population, according to a group of Maryland researchers.

The specific mechanisms underlying cardiovascular risk are only now being fully explored in this population, in part because RA patients often fail to present with the classic early signs and symptoms of cardiac disease, commented Dr. Jon Giles, who is a rheumatologist at the Johns Hopkins Division of Rheumatology in Baltimore, in a presentation given at the recent annual meeting of the American College of Rheumatology.

For example, Dr. Giles cited heart failure rates that are “nearly doubled” in RA patients.

Yet, “little is known about the myocardial changes that precede clinical heart failure in these patients,” he said.

Dr. Giles and his associates turned to cardiac MRI, a highly sensitive tool for assessing left ventricular structure and function, to hunt for preclinical risk factors for heart failure.

Rheumatoid arthritis patients with moderate disease (average 7 years' duration) who enrolled in the ESCAPE RA trial (n = 75) were compared with 775 participants in the Multi-Ethnic Study of Atherosclerosis who did not have RA. None of the members of either group had a history of cardiovascular events or procedures.

The rheumatoid arthritis cohort was younger than was the control group (mean age 59, compared with 63), and was also less likely to have a diagnosis of diabetes (4% versus 14%) or hypertension (32% versus 49%).

However, the patients' mean unadjusted left ventricular mass was 18% lower (120 g/m

The difference was particularly pronounced for male patients with RA, whose mean adjusted left ventricular mass was found to be fully 19% lower than that of men who did not have a rheumatoid arthritis diagnosis.

Female rheumatoid arthritis patients had a 9% lower left ventricular mass than did women without the inflammatory disease.

In both the RA and control groups, mean left ventricular mass decreased with age.

However, it was lower in rheumatoid arthritis patients than in controls in every age group, including the youngest patients in the study.

“In fact, the mean left ventricular mass was lower in 45-year-old RA patients than mean left ventricular mass in 80-year-old control patients, regardless of gender,” Dr. Giles commented during his podium presentation.

Left ventricular stroke volume was marginally lower in RA patients than in controls, significantly so in men.

“Small but significant” reductions in adjusted mean ejection fraction were seen as well, Dr. Giles said.

No differences were seen in RA patients and controls with regard to adjusted mean end diastolic volume.

The Johns Hopkins team also explored potentially significant associations between cardiovascular risk markers and RA disease characteristics such as disease severity, activity, treatment, and systemic inflammation.

They found only two factors that were independently associated with left ventricular mass, stroke volume, and end diastolic volume in rheumatoid arthritis patients.

One factor was increased anti-cyclic citrullinated peptide antibodies.

The other was the use of biological disease-modifying drugs (predominantly tumor necrosis factor-α inhibitors).

No characteristics were associated with ejection fraction.

The study findings raise intriguing questions about whether rheumatoid arthritis and its treatment heighten patients' cardiovascular risk through different mechanisms than in the general, non-RA population, said Dr. Giles.

For example, markedly lower left ventricular mass may reflect the “aftereffects” of subclinical myocarditis.

On the other hand, lower left ventricular mass measurements “may support the concept that RA is a disorder of accelerated aging,” he said.

Dr. Giles and his associates reported having no financial conflicts of interest with regard to this study.

ELSEVIER GLOBAL MEDICAL NEWS

DENVER, COLO. — A careful physical examination and history, with special attention to the family history, will detect most infants with gastroesophageal reflux who need an intensive work-up following an apparent life-threatening event, according to a review of 313 cases.

Apparent life-threatening events (ALTEs), which include observation of a color change, apnea, alteration in muscle tone, choking, and/or gagging, can have benign or pathologic etiologies, explained Dr. Ami Doshi at a meeting on pediatric hospital medicine, sponsored by the Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine.

“The overwhelming majority of patients look great by the time they present for medical attention,” said Dr. Doshi, of the Rady Children's Hospital and Health Center in San Diego.

Nonetheless, diagnostic uncertainty leads to expensive testing and sometimes lengthy hospitalization.

“This is not just an unclear entity, but also an incredibly common one,” she said. “These patients account for 2%–3% of pediatric inpatient visits in children under 1 year old.”

There is no standardized work-up, although a number of studies have attempted to elucidate which tests and predictive factors might distinguish healthy infants who could be safely discharged after an initial hospital evaluation, and which require more intensive investigation.

One study of 59 previously healthy infants, for example, found that 14% of hospitalizations were ultimately proven necessary, and that a history of multiple ALTEs in 24 hours and age of 1 month or younger had a combined negative predictive value of 100% (Pediatrics 2007;119:679–83).

Dr. Doshi and her associates were particularly interested in the 26%–54% of children with ALTEs whose working or final diagnosis was gastroesophageal reflux (GERD).

They conducted a retrospective chart review of cases in children up to 1 year old who were admitted with such events over a 3-year period at the tertiary children's hospital, which sees 800,000 patients a year. The hospital had developed a specific billing code for ALTEs that simplified the collection of cases. Only cases with at least a 6-month follow-up were included. The average age of babies included in the analysis was 2.1 months. Nearly half were Hispanic, reflecting the hospital's catchment area. Their length of stay was 2.5 days, ranging from 1 day to 66 days. In nearly 40%, a choking episode was the reported ALTE.

Roughly one-third were transported by emergency medical professionals, and 13% required rescue breaths.

An unusual family history was present in 15%.

The discharge diagnosis was GERD or upper respiratory illness in 80% of patients—a 96.6% concordance with the working diagnosis at admission. The “overwhelming majority” of GERD patients appeared well at the time of presentation, Dr. Doshi said.

Ten patients, however, suffered an event in the hospital, including central apnea, choking, oxygen desaturation, or cyanosis. One patient had a seizure and another, viral sepsis. All of these high-risk patients were less than 2.5 months old and 6 were born prematurely. Four had a concomitant diagnosis of bronchiolitis or upper respiratory infection.

“All 10 of these patients' events were directly attributable either to their prematurity or an intercurrent illness, rather than any new, unexpected, undetected diagnosis which we simply did not pick up at the time of admission,” she said during her oral presentation at the meeting. “Also, reassuringly, none of these 10 patients came back with a recurrent apparently life-threatening event or repeat admission.”

A 6-month follow-up found that 13 of the original 313 patients did suffer a recurrent ALTE, in most cases again due to GERD. These events occurred between 2 weeks and 5 months following discharge.

Other diagnoses in children with a recurrent ALTE included pertussis in one child, seizures in three, and cardiovascular abnormalities in two.

Clues to these later diagnoses were present in the records from the earlier admission, she said, either through noted symptoms such as noisy breathing (in the cardiac patients) or family history.

The family history repeatedly emerged as an important risk factor in the study. It was predictive of both a pathological diagnosis other than GERD and a recurrent ALTE in children with a final GERD diagnosis.

An abnormal family history was considered one that included seizures, genetic disease, congenital heart disease, failure to thrive, developmental delay, sudden infant death syndrome, or infant death(s).

DENVER, COLO. — A careful physical examination and history, with special attention to the family history, will detect most infants with gastroesophageal reflux who need an intensive work-up following an apparent life-threatening event, according to a review of 313 cases.

Apparent life-threatening events (ALTEs), which include observation of a color change, apnea, alteration in muscle tone, choking, and/or gagging, can have benign or pathologic etiologies, explained Dr. Ami Doshi at a meeting on pediatric hospital medicine, sponsored by the Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine.

“The overwhelming majority of patients look great by the time they present for medical attention,” said Dr. Doshi, of the Rady Children's Hospital and Health Center in San Diego.

Nonetheless, diagnostic uncertainty leads to expensive testing and sometimes lengthy hospitalization.

“This is not just an unclear entity, but also an incredibly common one,” she said. “These patients account for 2%–3% of pediatric inpatient visits in children under 1 year old.”

There is no standardized work-up, although a number of studies have attempted to elucidate which tests and predictive factors might distinguish healthy infants who could be safely discharged after an initial hospital evaluation, and which require more intensive investigation.

One study of 59 previously healthy infants, for example, found that 14% of hospitalizations were ultimately proven necessary, and that a history of multiple ALTEs in 24 hours and age of 1 month or younger had a combined negative predictive value of 100% (Pediatrics 2007;119:679–83).

Dr. Doshi and her associates were particularly interested in the 26%–54% of children with ALTEs whose working or final diagnosis was gastroesophageal reflux (GERD).

They conducted a retrospective chart review of cases in children up to 1 year old who were admitted with such events over a 3-year period at the tertiary children's hospital, which sees 800,000 patients a year. The hospital had developed a specific billing code for ALTEs that simplified the collection of cases. Only cases with at least a 6-month follow-up were included. The average age of babies included in the analysis was 2.1 months. Nearly half were Hispanic, reflecting the hospital's catchment area. Their length of stay was 2.5 days, ranging from 1 day to 66 days. In nearly 40%, a choking episode was the reported ALTE.

Roughly one-third were transported by emergency medical professionals, and 13% required rescue breaths.

An unusual family history was present in 15%.

The discharge diagnosis was GERD or upper respiratory illness in 80% of patients—a 96.6% concordance with the working diagnosis at admission. The “overwhelming majority” of GERD patients appeared well at the time of presentation, Dr. Doshi said.

Ten patients, however, suffered an event in the hospital, including central apnea, choking, oxygen desaturation, or cyanosis. One patient had a seizure and another, viral sepsis. All of these high-risk patients were less than 2.5 months old and 6 were born prematurely. Four had a concomitant diagnosis of bronchiolitis or upper respiratory infection.

“All 10 of these patients' events were directly attributable either to their prematurity or an intercurrent illness, rather than any new, unexpected, undetected diagnosis which we simply did not pick up at the time of admission,” she said during her oral presentation at the meeting. “Also, reassuringly, none of these 10 patients came back with a recurrent apparently life-threatening event or repeat admission.”

A 6-month follow-up found that 13 of the original 313 patients did suffer a recurrent ALTE, in most cases again due to GERD. These events occurred between 2 weeks and 5 months following discharge.

Other diagnoses in children with a recurrent ALTE included pertussis in one child, seizures in three, and cardiovascular abnormalities in two.

Clues to these later diagnoses were present in the records from the earlier admission, she said, either through noted symptoms such as noisy breathing (in the cardiac patients) or family history.

The family history repeatedly emerged as an important risk factor in the study. It was predictive of both a pathological diagnosis other than GERD and a recurrent ALTE in children with a final GERD diagnosis.

An abnormal family history was considered one that included seizures, genetic disease, congenital heart disease, failure to thrive, developmental delay, sudden infant death syndrome, or infant death(s).

DENVER, COLO. — A careful physical examination and history, with special attention to the family history, will detect most infants with gastroesophageal reflux who need an intensive work-up following an apparent life-threatening event, according to a review of 313 cases.

Apparent life-threatening events (ALTEs), which include observation of a color change, apnea, alteration in muscle tone, choking, and/or gagging, can have benign or pathologic etiologies, explained Dr. Ami Doshi at a meeting on pediatric hospital medicine, sponsored by the Academic Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine.

“The overwhelming majority of patients look great by the time they present for medical attention,” said Dr. Doshi, of the Rady Children's Hospital and Health Center in San Diego.

Nonetheless, diagnostic uncertainty leads to expensive testing and sometimes lengthy hospitalization.

“This is not just an unclear entity, but also an incredibly common one,” she said. “These patients account for 2%–3% of pediatric inpatient visits in children under 1 year old.”

There is no standardized work-up, although a number of studies have attempted to elucidate which tests and predictive factors might distinguish healthy infants who could be safely discharged after an initial hospital evaluation, and which require more intensive investigation.

One study of 59 previously healthy infants, for example, found that 14% of hospitalizations were ultimately proven necessary, and that a history of multiple ALTEs in 24 hours and age of 1 month or younger had a combined negative predictive value of 100% (Pediatrics 2007;119:679–83).

Dr. Doshi and her associates were particularly interested in the 26%–54% of children with ALTEs whose working or final diagnosis was gastroesophageal reflux (GERD).

They conducted a retrospective chart review of cases in children up to 1 year old who were admitted with such events over a 3-year period at the tertiary children's hospital, which sees 800,000 patients a year. The hospital had developed a specific billing code for ALTEs that simplified the collection of cases. Only cases with at least a 6-month follow-up were included. The average age of babies included in the analysis was 2.1 months. Nearly half were Hispanic, reflecting the hospital's catchment area. Their length of stay was 2.5 days, ranging from 1 day to 66 days. In nearly 40%, a choking episode was the reported ALTE.

Roughly one-third were transported by emergency medical professionals, and 13% required rescue breaths.

An unusual family history was present in 15%.

The discharge diagnosis was GERD or upper respiratory illness in 80% of patients—a 96.6% concordance with the working diagnosis at admission. The “overwhelming majority” of GERD patients appeared well at the time of presentation, Dr. Doshi said.

Ten patients, however, suffered an event in the hospital, including central apnea, choking, oxygen desaturation, or cyanosis. One patient had a seizure and another, viral sepsis. All of these high-risk patients were less than 2.5 months old and 6 were born prematurely. Four had a concomitant diagnosis of bronchiolitis or upper respiratory infection.

“All 10 of these patients' events were directly attributable either to their prematurity or an intercurrent illness, rather than any new, unexpected, undetected diagnosis which we simply did not pick up at the time of admission,” she said during her oral presentation at the meeting. “Also, reassuringly, none of these 10 patients came back with a recurrent apparently life-threatening event or repeat admission.”

A 6-month follow-up found that 13 of the original 313 patients did suffer a recurrent ALTE, in most cases again due to GERD. These events occurred between 2 weeks and 5 months following discharge.

Other diagnoses in children with a recurrent ALTE included pertussis in one child, seizures in three, and cardiovascular abnormalities in two.

Clues to these later diagnoses were present in the records from the earlier admission, she said, either through noted symptoms such as noisy breathing (in the cardiac patients) or family history.

The family history repeatedly emerged as an important risk factor in the study. It was predictive of both a pathological diagnosis other than GERD and a recurrent ALTE in children with a final GERD diagnosis.

An abnormal family history was considered one that included seizures, genetic disease, congenital heart disease, failure to thrive, developmental delay, sudden infant death syndrome, or infant death(s).

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest to tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus, and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

“I view the tetracyclines as the drugs I would like to save … for the future,” Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, suggested Dr. Baldwin of the State University of New York, Brooklyn.

“The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it,” she said.

Her strategy has been to use antibiotics “when necessary, but devise an exit strategy on day 1.”

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessary act quickly. By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued.

“On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide,” she advised, adding that even though it is bactericidal, no resistance develops in response to benzoyl peroxide.

“What I don't think people worry about are topical antibiotics,” she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence emerged in 2003 with a study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467–71).

A retrospective study looked at the charts of 118,496 patients, and found that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132–6).

“The issue is bigger than [Propionibacterium] acnes resistance or upper respiratory infections,” Dr. Baldwin said. “The whole thing ends up being a story of more severe organisms and MRSA.”

Community-acquired MRSA is increasingly familiar to dermatologists, because it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist, and pain is more severe than the clinical appearance of lesions might suggest.

“The treatment is drainage, drainage, drainage,” she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, “tetracyclines are probably the easiest drugs that we have to treat it,” she said. (See box.)

Dr. Baldwin disclosed ties with Allergan Inc., Coria Laboratories, Galderma S.A., GlaxoSmithKline, OrthoNeutrogena, Medicis Pharmaceutical Corp., Ranbaxy Pharmaceuticals Inc., Sanofi-Aventis, SkinMedica Inc., and Stiefel Laboratories Inc.

Agents in Hand and on the Horizon

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones: Promote emergence of MRSA.

Lincosamides (clindamycin): Resistance is growing. Covers some MRSA, but resistance to erythromycin may also signal resistance to clindamycin.

Glycopeptides: Resistance is increasing. Requires intravenous dosing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones: Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but effective for skin/soft tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer withdrew the application of this once-weekly injectable pending further study.

Telavancin: FDAhas indefinitely delayed the application of this injectable.

Ceftobiprole: The application of this new cephalosporin has been also been delayed indefinitely by the FDA.

Oral antibiotics: none.

Sources: Dr. Baldwin, Dr. Paul Holtom

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest to tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus, and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

“I view the tetracyclines as the drugs I would like to save … for the future,” Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, suggested Dr. Baldwin of the State University of New York, Brooklyn.

“The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it,” she said.

Her strategy has been to use antibiotics “when necessary, but devise an exit strategy on day 1.”

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessary act quickly. By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued.

“On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide,” she advised, adding that even though it is bactericidal, no resistance develops in response to benzoyl peroxide.

“What I don't think people worry about are topical antibiotics,” she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence emerged in 2003 with a study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467–71).

A retrospective study looked at the charts of 118,496 patients, and found that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132–6).

“The issue is bigger than [Propionibacterium] acnes resistance or upper respiratory infections,” Dr. Baldwin said. “The whole thing ends up being a story of more severe organisms and MRSA.”

Community-acquired MRSA is increasingly familiar to dermatologists, because it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist, and pain is more severe than the clinical appearance of lesions might suggest.

“The treatment is drainage, drainage, drainage,” she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, “tetracyclines are probably the easiest drugs that we have to treat it,” she said. (See box.)

Dr. Baldwin disclosed ties with Allergan Inc., Coria Laboratories, Galderma S.A., GlaxoSmithKline, OrthoNeutrogena, Medicis Pharmaceutical Corp., Ranbaxy Pharmaceuticals Inc., Sanofi-Aventis, SkinMedica Inc., and Stiefel Laboratories Inc.

Agents in Hand and on the Horizon

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones: Promote emergence of MRSA.

Lincosamides (clindamycin): Resistance is growing. Covers some MRSA, but resistance to erythromycin may also signal resistance to clindamycin.

Glycopeptides: Resistance is increasing. Requires intravenous dosing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones: Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but effective for skin/soft tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer withdrew the application of this once-weekly injectable pending further study.

Telavancin: FDAhas indefinitely delayed the application of this injectable.

Ceftobiprole: The application of this new cephalosporin has been also been delayed indefinitely by the FDA.

Oral antibiotics: none.

Sources: Dr. Baldwin, Dr. Paul Holtom

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest to tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus, and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

“I view the tetracyclines as the drugs I would like to save … for the future,” Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, suggested Dr. Baldwin of the State University of New York, Brooklyn.

“The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it,” she said.

Her strategy has been to use antibiotics “when necessary, but devise an exit strategy on day 1.”

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessary act quickly. By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued.

“On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide,” she advised, adding that even though it is bactericidal, no resistance develops in response to benzoyl peroxide.

“What I don't think people worry about are topical antibiotics,” she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence emerged in 2003 with a study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467–71).

A retrospective study looked at the charts of 118,496 patients, and found that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132–6).

“The issue is bigger than [Propionibacterium] acnes resistance or upper respiratory infections,” Dr. Baldwin said. “The whole thing ends up being a story of more severe organisms and MRSA.”

Community-acquired MRSA is increasingly familiar to dermatologists, because it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist, and pain is more severe than the clinical appearance of lesions might suggest.

“The treatment is drainage, drainage, drainage,” she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, “tetracyclines are probably the easiest drugs that we have to treat it,” she said. (See box.)

Dr. Baldwin disclosed ties with Allergan Inc., Coria Laboratories, Galderma S.A., GlaxoSmithKline, OrthoNeutrogena, Medicis Pharmaceutical Corp., Ranbaxy Pharmaceuticals Inc., Sanofi-Aventis, SkinMedica Inc., and Stiefel Laboratories Inc.

Agents in Hand and on the Horizon

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones: Promote emergence of MRSA.

Lincosamides (clindamycin): Resistance is growing. Covers some MRSA, but resistance to erythromycin may also signal resistance to clindamycin.

Glycopeptides: Resistance is increasing. Requires intravenous dosing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones: Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but effective for skin/soft tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer withdrew the application of this once-weekly injectable pending further study.

Telavancin: FDAhas indefinitely delayed the application of this injectable.

Ceftobiprole: The application of this new cephalosporin has been also been delayed indefinitely by the FDA.

Oral antibiotics: none.

Sources: Dr. Baldwin, Dr. Paul Holtom

SAN FRANCISCO — Patients who have rheumatoid arthritis should be assessed annually for cardiovascular risk factors, a recommendation necessitated by a heart disease risk profile that equates to that of those with type 2 diabeties, a European task force concluded.

“Cardiovascular risk management is urgently needed for patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis,” said Dr. Michael T. Nurmohame, who was speaking on behalf of the European League Against Rheumatism cardiovascular disease risk management task force at the annual meeting of the American College of Rheumatology.

Task force recommendations highlighted at the meeting included:

▸ Characterizing of rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis as “high-risk” conditions with regard to cardiovascular disease, similar to diabetes.

▸ Launching annual screening for cardiovascular risk of every RA patient, with consideration of screening of ankylosing spondylitis and psoriatic arthritis patients as well.

▸ Providing every patient with lifestyle recommendations for lowering cardiovascular risk.

▸ Emphasizing aggressive control of disease activity to suppress inflammation and lower cardiovascular risk.

▸ Adapting cardiovascular risk scoring models (such as the newly adapted Systematic Coronary Risk Evaluation SCORE) by a factor of 1.5 to account for elevated baseline risk associated with inflammatory rheumatic diseases.

▸ Considering of treatment with statins and/or antihypertensive drugs according to cardiovascular management targets established by local guidelines; or, if no local guidelines exist, when targets exceed 10-year cardiovascular mortality risk models established in the newly adapted SCORE.

▸ Acknowledging that the role of cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory drugs is not well established in RA patients.

▸ Limiting corticosteroids to the lowest possible doses.

The task force consisted of 21 rheumatologists, internists, cardiologists, and epidemiologists representing nine European countries.

Its work was prompted by the increasing recognition that those patients who have rheumatoid arthritis face a steeply elevated risk in cardiovascular diseases, said Dr. Nurmohamed, who is a rheumatologist at the VU University Medical Center and Jan van Breemen Institute in Amsterdam.

The risk can only be partially explained by traditional risk factors, with inflammatory processes serving as the apparent “missing link,” he suggested.

Earlier this year, Dr. Nurmohamed and his associates published the results of the CARRÉ study, in which they compared cardiovascular risk in 353 patients with rheumatoid arthritis with two groups of similarly aged patients who were enrolled in the population-based Hoorn cohort study: 194 of the patients had type 2 diabetes and 258 healthy controls (Ann. Rheum. Dis. 2008 Aug. 12 [doi:10.1136/ard.2008.094151]).

The prevalence of cardiovascular disease was 5% in nondiabetic patients with no rheumatoid arthritis; 12.4% in patients with type 2 diabetes; and 12.9% in patients with RA.

Some of that risk can be accounted for by increased hypertension, dyslipidemia, and lifestyle factors in the RA population, he said.

However, inflammatory rheumatic diseases themselves also seem to confer an independent risk that should be accounted for in models that predict cardiovascular mortality, Dr. Nurmohamed commented.

SAN FRANCISCO — Patients who have rheumatoid arthritis should be assessed annually for cardiovascular risk factors, a recommendation necessitated by a heart disease risk profile that equates to that of those with type 2 diabeties, a European task force concluded.

“Cardiovascular risk management is urgently needed for patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis,” said Dr. Michael T. Nurmohame, who was speaking on behalf of the European League Against Rheumatism cardiovascular disease risk management task force at the annual meeting of the American College of Rheumatology.

Task force recommendations highlighted at the meeting included:

▸ Characterizing of rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis as “high-risk” conditions with regard to cardiovascular disease, similar to diabetes.

▸ Launching annual screening for cardiovascular risk of every RA patient, with consideration of screening of ankylosing spondylitis and psoriatic arthritis patients as well.

▸ Providing every patient with lifestyle recommendations for lowering cardiovascular risk.

▸ Emphasizing aggressive control of disease activity to suppress inflammation and lower cardiovascular risk.

▸ Adapting cardiovascular risk scoring models (such as the newly adapted Systematic Coronary Risk Evaluation SCORE) by a factor of 1.5 to account for elevated baseline risk associated with inflammatory rheumatic diseases.

▸ Considering of treatment with statins and/or antihypertensive drugs according to cardiovascular management targets established by local guidelines; or, if no local guidelines exist, when targets exceed 10-year cardiovascular mortality risk models established in the newly adapted SCORE.

▸ Acknowledging that the role of cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory drugs is not well established in RA patients.

▸ Limiting corticosteroids to the lowest possible doses.

The task force consisted of 21 rheumatologists, internists, cardiologists, and epidemiologists representing nine European countries.

Its work was prompted by the increasing recognition that those patients who have rheumatoid arthritis face a steeply elevated risk in cardiovascular diseases, said Dr. Nurmohamed, who is a rheumatologist at the VU University Medical Center and Jan van Breemen Institute in Amsterdam.

The risk can only be partially explained by traditional risk factors, with inflammatory processes serving as the apparent “missing link,” he suggested.

Earlier this year, Dr. Nurmohamed and his associates published the results of the CARRÉ study, in which they compared cardiovascular risk in 353 patients with rheumatoid arthritis with two groups of similarly aged patients who were enrolled in the population-based Hoorn cohort study: 194 of the patients had type 2 diabetes and 258 healthy controls (Ann. Rheum. Dis. 2008 Aug. 12 [doi:10.1136/ard.2008.094151]).

The prevalence of cardiovascular disease was 5% in nondiabetic patients with no rheumatoid arthritis; 12.4% in patients with type 2 diabetes; and 12.9% in patients with RA.

Some of that risk can be accounted for by increased hypertension, dyslipidemia, and lifestyle factors in the RA population, he said.

However, inflammatory rheumatic diseases themselves also seem to confer an independent risk that should be accounted for in models that predict cardiovascular mortality, Dr. Nurmohamed commented.

SAN FRANCISCO — Patients who have rheumatoid arthritis should be assessed annually for cardiovascular risk factors, a recommendation necessitated by a heart disease risk profile that equates to that of those with type 2 diabeties, a European task force concluded.

“Cardiovascular risk management is urgently needed for patients with rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis,” said Dr. Michael T. Nurmohame, who was speaking on behalf of the European League Against Rheumatism cardiovascular disease risk management task force at the annual meeting of the American College of Rheumatology.

Task force recommendations highlighted at the meeting included:

▸ Characterizing of rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis as “high-risk” conditions with regard to cardiovascular disease, similar to diabetes.

▸ Launching annual screening for cardiovascular risk of every RA patient, with consideration of screening of ankylosing spondylitis and psoriatic arthritis patients as well.

▸ Providing every patient with lifestyle recommendations for lowering cardiovascular risk.

▸ Emphasizing aggressive control of disease activity to suppress inflammation and lower cardiovascular risk.

▸ Adapting cardiovascular risk scoring models (such as the newly adapted Systematic Coronary Risk Evaluation SCORE) by a factor of 1.5 to account for elevated baseline risk associated with inflammatory rheumatic diseases.

▸ Considering of treatment with statins and/or antihypertensive drugs according to cardiovascular management targets established by local guidelines; or, if no local guidelines exist, when targets exceed 10-year cardiovascular mortality risk models established in the newly adapted SCORE.

▸ Acknowledging that the role of cyclooxygenase-2 inhibitors and nonsteroidal anti-inflammatory drugs is not well established in RA patients.

▸ Limiting corticosteroids to the lowest possible doses.

The task force consisted of 21 rheumatologists, internists, cardiologists, and epidemiologists representing nine European countries.

Its work was prompted by the increasing recognition that those patients who have rheumatoid arthritis face a steeply elevated risk in cardiovascular diseases, said Dr. Nurmohamed, who is a rheumatologist at the VU University Medical Center and Jan van Breemen Institute in Amsterdam.

The risk can only be partially explained by traditional risk factors, with inflammatory processes serving as the apparent “missing link,” he suggested.

Earlier this year, Dr. Nurmohamed and his associates published the results of the CARRÉ study, in which they compared cardiovascular risk in 353 patients with rheumatoid arthritis with two groups of similarly aged patients who were enrolled in the population-based Hoorn cohort study: 194 of the patients had type 2 diabetes and 258 healthy controls (Ann. Rheum. Dis. 2008 Aug. 12 [doi:10.1136/ard.2008.094151]).

The prevalence of cardiovascular disease was 5% in nondiabetic patients with no rheumatoid arthritis; 12.4% in patients with type 2 diabetes; and 12.9% in patients with RA.

Some of that risk can be accounted for by increased hypertension, dyslipidemia, and lifestyle factors in the RA population, he said.

However, inflammatory rheumatic diseases themselves also seem to confer an independent risk that should be accounted for in models that predict cardiovascular mortality, Dr. Nurmohamed commented.

SANTA BARBARA, CALIF. — Enhanced survival of the smallest of premature infants presents special challenges to dermatologists tasked with caring for conditions arising from incomplete development of the skin.

Skin is a relatively early player in fetal development, with an epidermis present at 36 days that consists of a basal layer and a superficial peridermal layer. Ectodermal tissue gradually appears during organogenesis, and the stratum corneum begins to form around hair follicles at 14 weeks.

But the bridging of these cells into functional skin that includes an epidermal layer does not occur until 22–24 weeks' gestation, an age when preemies now survive at many institutions, said Dr. Lawrence F. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

Complications associated with extreme prematurity of the skin can continue to be seen in babies born at 29- or 30-weeks' gestation or even beyond. "The timing of this is interesting," he remarked.

"What we see with very premature infant skin is skin that doesn't quite have the thickness, doesn't have the adhesion … [of] mature skin," explained Dr. Eichenfield at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Translucent premature skin may be incapable of fully performing critical functions, leaving infants susceptible to fluid electrolyte loss, temperature dysregulation, injuries, infections, and increased uptake of potentially toxic agents.

One unusual physical consequence of underdeveloped skin is anetoderma of prematurity, characterized by tissue paper-like depressed brown scars or outpouchings of skin.

Although these lesions may not appear to be associated with overt trauma, they tellingly appear in areas where leads or adhesives have been placed, and most likely represent postinflammatory hyperpigmentation, said Dr. Eichenfield. "Look at the pattern of the lesions" to deduce their origin, he suggested.

Quite commonly, erosions and crusts that would be "banal" in other settings can become profound problems in extremely premature infants. For example, the tape used to adhere umbilical lines may erode the skin and lead to significant secondary infections.

The suction pressure produced when leads are removed can lead to ecchymosis in immature skin, or the ecchymosis can be a sign of invasive fungal infection. All too often, it can be hard to distinguish the two, said Dr. Eichenfield, also a professor of pediatrics and medicine at the University of California, San Diego.

One sign not to miss is diffuse superficial crusting around the umbilical line or elsewhere, which can be a tip off to invasion and colonization with cutaneous candidiasis. "This is important, because it is a significant player in mortality," he said.

Another critical troika of symptoms includes pustules/papules, ecchymosis, and crusts. When these three signs are present, opportunistic fungal infections should be a "very, very strong consideration," stressed Dr. Eichenfield.

Aspergillus and Rhizopus are only two of hundreds of fungi that may infect premature infants opportunistically, with extremely high rates of associated morbidity and mortality. "If you take care of it with debridement and systemic antifungals quickly, [while it remains confined to the skin], you save the child's life," he said.

Risk factors for fungal infection in preemies include corticosteroid and antibiotic use, adhesive tape, and hospital construction: the latter currently a major issue in California, since hospitals are racing to conform with state earthquake retrofitting standards. At Rady Children's Hospital, four or five cases of Aspergillus-associated fungal infections have been diagnosed in the past year or so, as construction progresses on the building and the surrounding medical complex, he noted.

When pustules, ecchymosis, and crusts are present, fungal infection should be a 'very, very strong consideration.' DR. EICHENFIELD

SANTA BARBARA, CALIF. — Enhanced survival of the smallest of premature infants presents special challenges to dermatologists tasked with caring for conditions arising from incomplete development of the skin.

Skin is a relatively early player in fetal development, with an epidermis present at 36 days that consists of a basal layer and a superficial peridermal layer. Ectodermal tissue gradually appears during organogenesis, and the stratum corneum begins to form around hair follicles at 14 weeks.

But the bridging of these cells into functional skin that includes an epidermal layer does not occur until 22–24 weeks' gestation, an age when preemies now survive at many institutions, said Dr. Lawrence F. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

Complications associated with extreme prematurity of the skin can continue to be seen in babies born at 29- or 30-weeks' gestation or even beyond. "The timing of this is interesting," he remarked.

"What we see with very premature infant skin is skin that doesn't quite have the thickness, doesn't have the adhesion … [of] mature skin," explained Dr. Eichenfield at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Translucent premature skin may be incapable of fully performing critical functions, leaving infants susceptible to fluid electrolyte loss, temperature dysregulation, injuries, infections, and increased uptake of potentially toxic agents.

One unusual physical consequence of underdeveloped skin is anetoderma of prematurity, characterized by tissue paper-like depressed brown scars or outpouchings of skin.

Although these lesions may not appear to be associated with overt trauma, they tellingly appear in areas where leads or adhesives have been placed, and most likely represent postinflammatory hyperpigmentation, said Dr. Eichenfield. "Look at the pattern of the lesions" to deduce their origin, he suggested.

Quite commonly, erosions and crusts that would be "banal" in other settings can become profound problems in extremely premature infants. For example, the tape used to adhere umbilical lines may erode the skin and lead to significant secondary infections.

The suction pressure produced when leads are removed can lead to ecchymosis in immature skin, or the ecchymosis can be a sign of invasive fungal infection. All too often, it can be hard to distinguish the two, said Dr. Eichenfield, also a professor of pediatrics and medicine at the University of California, San Diego.

One sign not to miss is diffuse superficial crusting around the umbilical line or elsewhere, which can be a tip off to invasion and colonization with cutaneous candidiasis. "This is important, because it is a significant player in mortality," he said.

Another critical troika of symptoms includes pustules/papules, ecchymosis, and crusts. When these three signs are present, opportunistic fungal infections should be a "very, very strong consideration," stressed Dr. Eichenfield.

Aspergillus and Rhizopus are only two of hundreds of fungi that may infect premature infants opportunistically, with extremely high rates of associated morbidity and mortality. "If you take care of it with debridement and systemic antifungals quickly, [while it remains confined to the skin], you save the child's life," he said.

Risk factors for fungal infection in preemies include corticosteroid and antibiotic use, adhesive tape, and hospital construction: the latter currently a major issue in California, since hospitals are racing to conform with state earthquake retrofitting standards. At Rady Children's Hospital, four or five cases of Aspergillus-associated fungal infections have been diagnosed in the past year or so, as construction progresses on the building and the surrounding medical complex, he noted.

When pustules, ecchymosis, and crusts are present, fungal infection should be a 'very, very strong consideration.' DR. EICHENFIELD

SANTA BARBARA, CALIF. — Enhanced survival of the smallest of premature infants presents special challenges to dermatologists tasked with caring for conditions arising from incomplete development of the skin.

Skin is a relatively early player in fetal development, with an epidermis present at 36 days that consists of a basal layer and a superficial peridermal layer. Ectodermal tissue gradually appears during organogenesis, and the stratum corneum begins to form around hair follicles at 14 weeks.

But the bridging of these cells into functional skin that includes an epidermal layer does not occur until 22–24 weeks' gestation, an age when preemies now survive at many institutions, said Dr. Lawrence F. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.

Complications associated with extreme prematurity of the skin can continue to be seen in babies born at 29- or 30-weeks' gestation or even beyond. "The timing of this is interesting," he remarked.

"What we see with very premature infant skin is skin that doesn't quite have the thickness, doesn't have the adhesion … [of] mature skin," explained Dr. Eichenfield at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Translucent premature skin may be incapable of fully performing critical functions, leaving infants susceptible to fluid electrolyte loss, temperature dysregulation, injuries, infections, and increased uptake of potentially toxic agents.

One unusual physical consequence of underdeveloped skin is anetoderma of prematurity, characterized by tissue paper-like depressed brown scars or outpouchings of skin.

Although these lesions may not appear to be associated with overt trauma, they tellingly appear in areas where leads or adhesives have been placed, and most likely represent postinflammatory hyperpigmentation, said Dr. Eichenfield. "Look at the pattern of the lesions" to deduce their origin, he suggested.

Quite commonly, erosions and crusts that would be "banal" in other settings can become profound problems in extremely premature infants. For example, the tape used to adhere umbilical lines may erode the skin and lead to significant secondary infections.

The suction pressure produced when leads are removed can lead to ecchymosis in immature skin, or the ecchymosis can be a sign of invasive fungal infection. All too often, it can be hard to distinguish the two, said Dr. Eichenfield, also a professor of pediatrics and medicine at the University of California, San Diego.

One sign not to miss is diffuse superficial crusting around the umbilical line or elsewhere, which can be a tip off to invasion and colonization with cutaneous candidiasis. "This is important, because it is a significant player in mortality," he said.

Another critical troika of symptoms includes pustules/papules, ecchymosis, and crusts. When these three signs are present, opportunistic fungal infections should be a "very, very strong consideration," stressed Dr. Eichenfield.

Aspergillus and Rhizopus are only two of hundreds of fungi that may infect premature infants opportunistically, with extremely high rates of associated morbidity and mortality. "If you take care of it with debridement and systemic antifungals quickly, [while it remains confined to the skin], you save the child's life," he said.

Risk factors for fungal infection in preemies include corticosteroid and antibiotic use, adhesive tape, and hospital construction: the latter currently a major issue in California, since hospitals are racing to conform with state earthquake retrofitting standards. At Rady Children's Hospital, four or five cases of Aspergillus-associated fungal infections have been diagnosed in the past year or so, as construction progresses on the building and the surrounding medical complex, he noted.

When pustules, ecchymosis, and crusts are present, fungal infection should be a 'very, very strong consideration.' DR. EICHENFIELD

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest-to-tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus (MRSA), and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

"I view the tetracyclines as the drugs I would like to save … for the future," Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, suggested Dr. Baldwin of the State University of New York, Brooklyn.

"The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it," she said.

Her strategy has been to "utilize antibiotics when necessary, but devise an exit strategy on day 1."

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessary act quickly.

By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued.

"On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide," she advised.

Even though it is bactericidal, no resistance develops in response to benzoyl peroxide, she said.

"What I don't think people worry about are topical antibiotics," she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence arrived in 2003 with a disturbing study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467-71).

Another study looked retrospectively at the charts of 118,496 patients, finding that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132-6).

"The issue is bigger than [Propionibacterium] acnes resistance or upper respiratory infections," Dr. Baldwin said. "The whole thing ends up being a story of more severe organisms and MRSA."

Community-acquired MRSA is increasingly familiar to dermatologists, since it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist, and pain is more severe than the clinical appearance of lesions might suggest.

"The treatment is drainage, drainage, drainage," she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, "tetracyclines are probably the easiest drugs that we have to treat it," she said. (See box.)

"Do we overprescribe antibiotics? Of course we do," Dr. Baldwin said. Dermatologists write 8–9 million prescriptions a year for antibiotics and 40%–50% of all prescriptions for tetracyclines.

The reasons are many: not wanting to miss infections, avoiding medicolegal problems, and basically just wanting a quick response to inflammatory conditions such as acne and rosacea. "Sometimes patients just wear us the heck down," she admitted.

Dr. Baldwin disclosed ties with Allergan Inc., Coria Laboratories, Galderma S.A., GlaxoSmithKline, OrthoNeutrogena, Medicis Pharmaceutical Corp., Ranbaxy Pharmaceuticals Inc., Sanofi-Aventis, SkinMedica Inc., and Stiefel Laboratories Inc.

'The message is getting out … that antibiotic resistance is here, it's now, and we have to worry about it.' DR. BALDWIN

Antibiotic Choices for MRSA Reviewed

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective against MRSA.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones (ciprofloxacin, levofloxacin, etc.): Promote emergence of MRSA.

Lincosamides (clindamycin): Resistance is growing. Covers some MRSA, but resistance to erythromycin may signal resistance to clindamycin as well, even if culture suggests sensitivity.

Glycopeptides (vancomycin): Resistance is increasing. Requires intravenous dosing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones (linezolid, etc.): Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but very effective for skin/soft-tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer withdrew the application of this once-weekly injectable pending further study.

Telavancin: The application of this injectable has been delayed indefinitely by the Food and Drug Administration.

Ceftobiprole: The application of this new cephalosporin has been delayed indefinitely by the FDA.

Oral antibiotics in development for MRSA: none.

Sources: Dr. Baldwin, Dr. Paul Holtom

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest-to-tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus (MRSA), and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

"I view the tetracyclines as the drugs I would like to save … for the future," Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, suggested Dr. Baldwin of the State University of New York, Brooklyn.

"The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it," she said.

Her strategy has been to "utilize antibiotics when necessary, but devise an exit strategy on day 1."

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessary act quickly.

By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued.

"On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide," she advised.

Even though it is bactericidal, no resistance develops in response to benzoyl peroxide, she said.

"What I don't think people worry about are topical antibiotics," she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence arrived in 2003 with a disturbing study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467-71).

Another study looked retrospectively at the charts of 118,496 patients, finding that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132-6).

"The issue is bigger than [Propionibacterium] acnes resistance or upper respiratory infections," Dr. Baldwin said. "The whole thing ends up being a story of more severe organisms and MRSA."

Community-acquired MRSA is increasingly familiar to dermatologists, since it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist, and pain is more severe than the clinical appearance of lesions might suggest.

"The treatment is drainage, drainage, drainage," she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, "tetracyclines are probably the easiest drugs that we have to treat it," she said. (See box.)

"Do we overprescribe antibiotics? Of course we do," Dr. Baldwin said. Dermatologists write 8–9 million prescriptions a year for antibiotics and 40%–50% of all prescriptions for tetracyclines.

The reasons are many: not wanting to miss infections, avoiding medicolegal problems, and basically just wanting a quick response to inflammatory conditions such as acne and rosacea. "Sometimes patients just wear us the heck down," she admitted.

Dr. Baldwin disclosed ties with Allergan Inc., Coria Laboratories, Galderma S.A., GlaxoSmithKline, OrthoNeutrogena, Medicis Pharmaceutical Corp., Ranbaxy Pharmaceuticals Inc., Sanofi-Aventis, SkinMedica Inc., and Stiefel Laboratories Inc.

'The message is getting out … that antibiotic resistance is here, it's now, and we have to worry about it.' DR. BALDWIN

Antibiotic Choices for MRSA Reviewed

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective against MRSA.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones (ciprofloxacin, levofloxacin, etc.): Promote emergence of MRSA.

Lincosamides (clindamycin): Resistance is growing. Covers some MRSA, but resistance to erythromycin may signal resistance to clindamycin as well, even if culture suggests sensitivity.

Glycopeptides (vancomycin): Resistance is increasing. Requires intravenous dosing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones (linezolid, etc.): Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but very effective for skin/soft-tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer withdrew the application of this once-weekly injectable pending further study.

Telavancin: The application of this injectable has been delayed indefinitely by the Food and Drug Administration.

Ceftobiprole: The application of this new cephalosporin has been delayed indefinitely by the FDA.

Oral antibiotics in development for MRSA: none.

Sources: Dr. Baldwin, Dr. Paul Holtom

SANTA BARBARA, CALIF. — Tetracyclines may wind up being the safest, cheapest, easiest-to-tolerate nonintravenous drugs available to treat future cases of methicillin-resistant Staphylococcus aureus (MRSA), and that should be reason enough to get on the bandwagon to preserve tetracycline's potency through wise use, according to one dermatologist.

"I view the tetracyclines as the drugs I would like to save … for the future," Dr. Hilary Baldwin said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dermatologic prescribing of antibiotics for acne and rosacea, as well as for skin infections, may be driving resistance in unexpected ways, suggested Dr. Baldwin of the State University of New York, Brooklyn.

"The message is getting out to dermatologists and nondermatologists that antibiotic resistance is here, it's now, and we have to worry about it," she said.

Her strategy has been to "utilize antibiotics when necessary, but devise an exit strategy on day 1."

For example, she may prescribe a topical retinoid, hormonal therapy, or an androgen receptor blocker alongside an antibiotic, so that the time clock will begin ticking right away for nonantibiotic workhorses that don't necessary act quickly.

By the time a topical retinoid really is beginning to take hold—at about 12 weeks—the antibiotic will have produced quick, patient-pleasing results and can be discontinued.

"On the day you stop topical or oral antibiotics [while continuing the alternative medication], also start benzoyl peroxide," she advised.

Even though it is bactericidal, no resistance develops in response to benzoyl peroxide, she said.

"What I don't think people worry about are topical antibiotics," she said, noting that the timing of serious resistance problems coincides with the introduction of topical erythromycin and clindamycin.

More specific evidence arrived in 2003 with a disturbing study showing tetracycline-resistant Streptococcus pyogenes in the throats of 85% of long-term users of topical or oral antibiotics, compared with 20% of controls (Arch. Dermatol. 2003;139:467-71).

Another study looked retrospectively at the charts of 118,496 patients, finding that patients who had received 6 weeks or more of topical or systemic antibiotics were at more than a twofold risk of upper respiratory infections (Arch. Dermatol. 2005;141:1132-6).

"The issue is bigger than [Propionibacterium] acnes resistance or upper respiratory infections," Dr. Baldwin said. "The whole thing ends up being a story of more severe organisms and MRSA."

Community-acquired MRSA is increasingly familiar to dermatologists, since it presents as skin and soft-tissue infections in 85% of cases. Abscesses often occur below the waist, and pain is more severe than the clinical appearance of lesions might suggest.

"The treatment is drainage, drainage, drainage," she said, adding that it most often works in the sentinel patient. Contacts at home, especially siblings, may develop severe necrotizing pneumonia and death.

When MRSA does get nasty, "tetracyclines are probably the easiest drugs that we have to treat it," she said. (See box.)

"Do we overprescribe antibiotics? Of course we do," Dr. Baldwin said. Dermatologists write 8–9 million prescriptions a year for antibiotics and 40%–50% of all prescriptions for tetracyclines.

The reasons are many: not wanting to miss infections, avoiding medicolegal problems, and basically just wanting a quick response to inflammatory conditions such as acne and rosacea. "Sometimes patients just wear us the heck down," she admitted.

Dr. Baldwin disclosed ties with Allergan Inc., Coria Laboratories, Galderma S.A., GlaxoSmithKline, OrthoNeutrogena, Medicis Pharmaceutical Corp., Ranbaxy Pharmaceuticals Inc., Sanofi-Aventis, SkinMedica Inc., and Stiefel Laboratories Inc.

'The message is getting out … that antibiotic resistance is here, it's now, and we have to worry about it.' DR. BALDWIN

Antibiotic Choices for MRSA Reviewed

Currently Available Antibiotics

Tetracyclines: Cover 80% of MRSA.

Penicillins/cephalosporins: Ineffective against MRSA.

Trimethoprim-sulfamethoxazole: Reasonable, cheap; sufficient to cover most MRSA but not Streptococcus.

Fluoroquinolones (ciprofloxacin, levofloxacin, etc.): Promote emergence of MRSA.

Lincosamides (clindamycin): Resistance is growing. Covers some MRSA, but resistance to erythromycin may signal resistance to clindamycin as well, even if culture suggests sensitivity.

Glycopeptides (vancomycin): Resistance is increasing. Requires intravenous dosing. Not effective for many serious infections.

Streptogramins: Effective, but require intravenous dosing. They are very expensive and have major adverse effects.

Oxazolidinones (linezolid, etc.): Oral, but very expensive, with significant adverse effects. Resistance is developing.

Daptomycin: Intravenous only, but very effective for skin/soft-tissue infections.

Tigecycline: The newest antibiotic is intravenous only, but very effective.

Drugs on the Horizon

Dalbavancin: Pfizer withdrew the application of this once-weekly injectable pending further study.

Telavancin: The application of this injectable has been delayed indefinitely by the Food and Drug Administration.

Ceftobiprole: The application of this new cephalosporin has been delayed indefinitely by the FDA.

Oral antibiotics in development for MRSA: none.

Sources: Dr. Baldwin, Dr. Paul Holtom

SAN FRANCISCO — Preliminary research suggests that rheumatoid arthritis patients who quit smoking may experience fewer swollen and tender joints and improved C-reactive protein levels, among other measures of improved disease activity, according to a presentation at the annual meeting of the American College of Rheumatology.

In the first known study of the impact of active smoking cessation in RA, Dr. Mark C. Fisher and his associates at the New York University Medical Center Hospital for Joint Diseases examined markers of disease progression in patients who quit smoking, compared with those who continued to smoke.

The cross-sectional study examined records for 16,521 patients with active rheumatoid arthritis, of whom 2,328 were current smokers at baseline. At an average follow-up of 3.5 years, 328 of these smokers had quit successfully, according to at least 2 consecutive self-reports at clinic visits spaced about 3 months apart.

At baseline, no differences were seen between the patients who eventually quit and those who continued to smoke in terms of disease duration, rheumatoid factor or cyclic citrullinated peptide (CCP) status, or medication type or use.

Nonetheless, at their final clinic visit for the study, the smokers who had quit had a lower mean Clinical Disease Activity Index (14 versus 11.5), which reflected a reduced number of swollen and tender joints and lower C-reactive protein level, a marker of inflammation.

When this difference was adjusted for potentially confounding variables, the relationship remained “statistically significant, and probably clinically significant as well,” but less powerful, said Dr. Fisher, a research fellow, in an interview at the meeting.

An intriguing finding within the adjusted data was the fact that quitters with more severe disease at baseline appeared to have the greatest improvement on their Clinical Disease Activity Index scores as well as patient- and physician-assessed global improvement. “Remission data were even more impressive,” said Dr. Fisher.

In an unadjusted model, 12.3% of patients who continued to smoke were in remission at the final follow-up visit, compared with 18.6% of those who quit. The difference remained “highly statistically significant” even after adjustment for potentially confounding variables. To find that quitters were 1.49 times more likely to go into remission is powerful, he said, even in a “snapshot” cross-sectional study.

A longitudinal study is being planned, said Dr. Fisher. He reported no disclosures with regard to funding of the study.

Quitters with more severe diseaseat baseline had the greatest improvement on their disease activity scores. DR. FISHER

SAN FRANCISCO — Preliminary research suggests that rheumatoid arthritis patients who quit smoking may experience fewer swollen and tender joints and improved C-reactive protein levels, among other measures of improved disease activity, according to a presentation at the annual meeting of the American College of Rheumatology.

In the first known study of the impact of active smoking cessation in RA, Dr. Mark C. Fisher and his associates at the New York University Medical Center Hospital for Joint Diseases examined markers of disease progression in patients who quit smoking, compared with those who continued to smoke.

The cross-sectional study examined records for 16,521 patients with active rheumatoid arthritis, of whom 2,328 were current smokers at baseline. At an average follow-up of 3.5 years, 328 of these smokers had quit successfully, according to at least 2 consecutive self-reports at clinic visits spaced about 3 months apart.

At baseline, no differences were seen between the patients who eventually quit and those who continued to smoke in terms of disease duration, rheumatoid factor or cyclic citrullinated peptide (CCP) status, or medication type or use.

Nonetheless, at their final clinic visit for the study, the smokers who had quit had a lower mean Clinical Disease Activity Index (14 versus 11.5), which reflected a reduced number of swollen and tender joints and lower C-reactive protein level, a marker of inflammation.

When this difference was adjusted for potentially confounding variables, the relationship remained “statistically significant, and probably clinically significant as well,” but less powerful, said Dr. Fisher, a research fellow, in an interview at the meeting.

An intriguing finding within the adjusted data was the fact that quitters with more severe disease at baseline appeared to have the greatest improvement on their Clinical Disease Activity Index scores as well as patient- and physician-assessed global improvement. “Remission data were even more impressive,” said Dr. Fisher.

In an unadjusted model, 12.3% of patients who continued to smoke were in remission at the final follow-up visit, compared with 18.6% of those who quit. The difference remained “highly statistically significant” even after adjustment for potentially confounding variables. To find that quitters were 1.49 times more likely to go into remission is powerful, he said, even in a “snapshot” cross-sectional study.

A longitudinal study is being planned, said Dr. Fisher. He reported no disclosures with regard to funding of the study.

Quitters with more severe diseaseat baseline had the greatest improvement on their disease activity scores. DR. FISHER

SAN FRANCISCO — Preliminary research suggests that rheumatoid arthritis patients who quit smoking may experience fewer swollen and tender joints and improved C-reactive protein levels, among other measures of improved disease activity, according to a presentation at the annual meeting of the American College of Rheumatology.

In the first known study of the impact of active smoking cessation in RA, Dr. Mark C. Fisher and his associates at the New York University Medical Center Hospital for Joint Diseases examined markers of disease progression in patients who quit smoking, compared with those who continued to smoke.

The cross-sectional study examined records for 16,521 patients with active rheumatoid arthritis, of whom 2,328 were current smokers at baseline. At an average follow-up of 3.5 years, 328 of these smokers had quit successfully, according to at least 2 consecutive self-reports at clinic visits spaced about 3 months apart.

At baseline, no differences were seen between the patients who eventually quit and those who continued to smoke in terms of disease duration, rheumatoid factor or cyclic citrullinated peptide (CCP) status, or medication type or use.

Nonetheless, at their final clinic visit for the study, the smokers who had quit had a lower mean Clinical Disease Activity Index (14 versus 11.5), which reflected a reduced number of swollen and tender joints and lower C-reactive protein level, a marker of inflammation.

When this difference was adjusted for potentially confounding variables, the relationship remained “statistically significant, and probably clinically significant as well,” but less powerful, said Dr. Fisher, a research fellow, in an interview at the meeting.

An intriguing finding within the adjusted data was the fact that quitters with more severe disease at baseline appeared to have the greatest improvement on their Clinical Disease Activity Index scores as well as patient- and physician-assessed global improvement. “Remission data were even more impressive,” said Dr. Fisher.

In an unadjusted model, 12.3% of patients who continued to smoke were in remission at the final follow-up visit, compared with 18.6% of those who quit. The difference remained “highly statistically significant” even after adjustment for potentially confounding variables. To find that quitters were 1.49 times more likely to go into remission is powerful, he said, even in a “snapshot” cross-sectional study.

A longitudinal study is being planned, said Dr. Fisher. He reported no disclosures with regard to funding of the study.

Quitters with more severe diseaseat baseline had the greatest improvement on their disease activity scores. DR. FISHER