Impact of liposomal amphotericin B on renal function in critically ill patients with renal function impairment

OBJECTIVE

To assess the tolerability of liposomal amphotericin B (L-AmB) in critically ill patients with elevated serum creatinine concentrations (Cr) (> 1.5 mg/dL) at starting L-AmB therapy.

METHODS

Retrospective, multicenter, comparative study of two cohorts of critically ill patients treated with L-AmB during 3 or more days, the difference between them was the level of Cr at the beginning of treatment. A cutoff value of Cr of 1.5 mg/dL was established. Patients undergoing extrarenal depuration procedures before or 48 hours after starting L-AmB were excluded. The primary endpoint was the difference between Cr values at the end of treatment as compared with Cr at starting L-AmB. Secondary endpoints were treatment-related withdrawals, need of extrarenal depuration techniques, and treatment-related severe adverse events. Demographic data, underlying illness, indication of L-AmB therapy, concomitant risk factors of nephrotoxicity, and vital status at ICU and hospital discharge were recorded.

RESULTS

A total of 122 patients admitted to 26 ICUs (16 with Cr > 1.5 g/dL; 106 with normal Cr levels) were recruited. Main reasons for the use of L-AmB in both groups were the broad spectrum of the drug and the presence of hemodynamic instability. L-AmB was administered as first-line treatment in 68.8% of patients with elevated Cr and in 52.8% with normal Cr. The APACHE II score on ICU admission was 25 in patients with elevated Cr and 17 in those with normal Cr values (p < 0.001). Duration of treatment with L-AmB was 16 and 12 days in patients with elevate and normal Cr values, respectively, with a mean dose of 3.5 vs 3.9 mg/kg/day. The use of concomitant nephrotoxic drugs, mortality rate, and ICU and hospital length of stay were similar in both cohorts. In patients with renal function impairment at the initiation of L-AmB treatment, an absolute decrease of Cf-Ci of 1.08 mg/dL was observed (P < 0.001). A decrease of Cr levels to normal limits was observed in 50% of the patients; in 37.5% of patients there was a decrease but normal levels were not achieved, whereas a Cr increased occurred in only one (6.25%) patient. None of the patients required withdrawal of L-AmB or use of extrarenal depuration procedures. Treatment-related severe adverse events were not reported.

CONCLUSIONS

In critically ill patients with impaired renal function, the impact of L-AmB on renal function was minimal. L-AmB can be used for the treatment of fungal infections in critically ill patients independently of renal function at the initiation of treatment.

[Compartment syndrome after cardiopulmonary bypass]

Compartment syndrome of the lower leg is an occasional complication of prolonged ischemia and reperfusion. We present a patient with compartment syndrome of the ipsilateral thigh after femoral arterial and venous cannulation for cardiopulmonary bypass.

Internal consistency, temporal stability, and reproducibility of individual index scores of the Test of Variables of Attention in children with attention-deficit/hyperactivity disorder

Psychometric properties of the Test of Variables of Attention (TOVA) were examined in a cohort of children (n=63) strictly diagnosed with attention-deficit/hyperactivity disorder (AD/HD). Internal consistency was assessed via correlational analyses to determine the degree of agreement among various test portions. The temporal stability of errors of omission, errors of commission, response time, and response time variability was evaluated using test-retest reliability. Reproducibility of individual scores for the same indices was assessed using the Bland-Altman procedure. Select TOVA index scores exhibited high internal consistency in this cohort. Although the temporal stability of group scores (test-retest reliability) was satisfactory, individual test scores were less reproducible. Temporal stability and individual test-retest score agreement were greater for response time and response time variability than for errors of omission and errors of commission.

A randomized, double-blind, placebo-controlled trial of docosahexaenoic acid supplementation in children with attention-deficit/hyperactivity disorder

OBJECTIVE

To determine whether docosahexaenoic acid (DHA) supplementation for 4 months decreases the symptoms of attention-deficit/hyperactivity disorder (ADHD).

STUDY DESIGN

Sixty-three 6- to-12-year-old children with ADHD, all receiving effective maintenance therapy with stimulant medication, were assigned randomly, in a double-blind fashion, to receive DHA supplementation (345 mg/d) or placebo for 4 months. Outcome variables included plasma phospholipid fatty acid patterns, scores on laboratory measures of inattention and impulsivity (Test of Variables of Attention, Children's Color Trails test) while not taking stimulant medication, and scores on parental behavioral rating scales (Child Behavior Checklist, Conners' Rating Scale). Differences between groups after 4 months of DHA supplementation or placebo administration were determined by analysis of variance, controlling for age, baseline value of each outcome variable, ethnicity, and ADHD subtype.

RESULTS

Plasma phospholipid DHA content of the DHA-supplemented group was 2.6-fold higher at the end of the study than that of the placebo group (4.85 +/- 1.35 vs 1.86 +/- 0.87 mol % of total fatty acids; P <.001). Despite this, there was no statistically significant improvement in any objective or subjective measure of ADHD symptoms.

CONCLUSION

A 4-month period of DHA supplementation (345 mg/d) does not decrease symptoms of ADHD.

Early predictors of neurodevelopmental outcome in symptomatic congenital cytomegalovirus infection

OBJECTIVE

To determine the ability of neonatal clinical, audiologic, and computed tomography (CT) findings to predict long-term neurodevelopmental outcome in children with symptomatic congenital cytomegalovirus (CMV) infection.

METHODS

Longitudinal cohort study of children (n = 41) with symptomatic congenital CMV infection evaluated at birth and followed up with serial age-appropriate neurodevelopmental testing. The performance of birth characteristics as predictors of long-term outcome were determined, and clinical and CT scoring systems were developed and correlated with intellectual outcome.

RESULTS

Microcephaly was the most specific predictor of mental retardation (100%; 95% CI 84.5-100) and major motor disability (92.3%; 95% CI 74.8-99). An abnormality detected by CT was the most sensitive predictor for mental retardation (100%; 95% CI 82.3-100) and motor disability (100%; 95% CI 78.2-100). A highly significant (P <.001) positive correlation was found between head size at birth and the intelligence/developmental quotient (IQ/DQ). Approximately 29% of children had an IQ/DQ >90. There was no association between sensorineural hearing loss at birth and cognitive outcome. However, children with sensorineural hearing loss on follow-up (congenital and late-onset) had a lower IQ/DQ (P =.006) than those with normal hearing.

CONCLUSIONS

The presence of microcephaly at birth was the most specific predictor of poor cognitive outcome in children with symptomatic congenital CMV infection, whereas children with normal findings on head CT and head circumference proportional to weight exhibited a good cognitive outcome.

Long-term effects of high-dose zidovudine treatment on neuropsychological performance in mildly symptomatic HIV-positive patients: results of a randomized, double-blind, placebo-controlled investigation

This study examined the treatment outcome of high-dose (1500 mg/day) zidovudine (AZT) on neuropsychological (NP) functioning (Trailmaking Test A & B, WAIS-R Digit Symbol, and Rey Auditory Verbal Learning Test) across a 12-month period in mildly symptomatic HIV-1 seropositive men (n = 46 at entry) enrolled in a randomized, double-blind, placebo-controlled trial (VA Cooperative Studies Program #298). Neither short-term (0-6 months) nor long-term (0-12 months) AZT administration revealed enhancement in NP performance. The results suggest that, although AZT may afford patients prophylactic benefits, protracted high-dose AZT treatment does not improve NP functioning in mildly symptomatic HIV-positive individuals.

Effects of test administration order on children's neuropsychological performance: emerging one-word expressive and receptive language skills

Differences in neuropsychological performance associated with specific test presentation sequences have been reported in adults. However, these effects have received little attention in children. The EOWPVT-R, a measure of one-word expressive language, and the PPVT-R, a measure of receptive language, were administered to 6- to 14-year-olds (control [n = 17] and experimental [n = 22] groups) in a counterbalanced fashion to investigate the potential effects of test presentation sequence on neuropsychological performance. Group findings were not evidenced subsequent to variation in test administration sequence. In contrast, order of test presentation revealed differences in performance. Administration of the PPVT-R prior to the EOWPVT-R resulted in enhanced EOWPVT-R expressive language scores in both groups of participants. Presentation of the PPVT-R after the EOWPVT-R did not affect performance. Applied and theoretical implications associated with these findings are discussed.

Patterns of American immigration and their influence on the acquisition of neuropsychological norms for Hispanics

This article examines patterns of legal American immigration (migrations to the United States from abroad) and their direct impact on the acquisition of neuropsychological (NP) normative data for Hispanics. The nonrandom and selective nature of these migrations, and their accompanying demographic attributes, are shown to significantly influence the acquisition process. Specifically, the direct impact of several potential sources of bias while procuring NP norms is explored. Total number of immigrants (absolute immigration), occupational allegiance (and possibly education), and intended area of initial residence seem to play influential roles as a result of their direct impact on demographic characteristics known to have significant effects on neuropsychological performance. Possible solutions capable of enhancing the acquisition process are also addressed.

Stimulant medications decrease energy expenditure and physical activity in children with attention-deficit/hyperactivity disorder

OBJECTIVE

To determine the effect of stimulant medications used to treat children with attention-deficit/hyperactivity disorder (AD/HD) on energy expenditure, fuel utilization, and physical activity.

STUDY DESIGN

Energy expenditure and physical activity were measured, respectively, by room respiration calorimetry and microwave motion detectors in 31 children with AD/HD (26 boys and 5 girls; ages 6 to 12 years) both while they were receiving their prescribed stimulant medication and after the medication had been discontinued for at least 24 hours. Fuel utilization was calculated from calorimetry data.

RESULTS

Total and awake energy expenditure including energy expended while doing schoolwork, riding a stationary bicycle, resting, and watching a movie were from 4% to 8% lower when the children were receiving their prescribed stimulant medication. Total and awake activity were also lower while they were receiving medication (16% to 22%) and accounted for the lower rates of energy expenditure. Sleeping metabolic rate, basal metabolic rate, and fuel utilization were unaffected by medication.

CONCLUSIONS

Stimulant medications decrease physical activity, and hence, decrease the activity component of total daily energy expenditure in children with AD/HD.

Slowed information processing in HIV-1 disease. The Multicenter AIDS Cohort Study (MACS)

This investigation examined the effects of HIV-1 infection on speeded complex cognitive processing in a group of HIV-negative (n = 666), HIV-positive symptomatic (n = 156), and HIV-positive asymptomatic (n = 623) participants while controlling for the effects of slowed motor functioning, peripheral neuropathy, and several other putative confounds. Stroop Interference and reaction-time tasks served as anchor procedures to assess cognitive processing. The present findings suggest that HIV-1 infection is capable of compromising CNS-mediated cognitive processes (speeded processing) infringing upon their efficacy in the symptomatic stages of the disease while sparing individuals in the asymptomatic stage. The detrimental effects observed on information-processing mechanisms associated with HIV infection persisted despite the use of procedures to control for peripheral nerve integrity and other potential confounds.

Behavior analysis of motion control for pediatric neuroimaging

Magnetic resonance imaging is a promising technological advance used for research and diagnosis of disease. The procedure has no risks, except when uncooperative patients require sedation. Four normal children participated in simulated scans to study the effects of (a) antecedent changes in the imaging environment and (b) operant conditioning of movement inhibition. Changing the environment can decrease movement, but operant contingencies were necessary to decrease movement to a level that, in most cases, would allow the procedure to occur without sedation.