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Biomedical subjects

R C Wachtel

Publications and source records attributed to R C Wachtel.

At least 19 recordsLinked to original sources
PubMed1998

Neurodevelopmental/neuroradiologic recovery of a child infected with HIV after treatment with combination antiretroviral therapy using the HIV-specific protease inhibitor ritonavir.

BACKGROUND: Neurodevelopmental impairment has been identified in children infected with human immunodeficiency virus (HIV). The frequency and spectrum of neurologic impairment are greater in children than those reported for adults. In children, HIV is known to enter the central nervous system early in the course of the disease. The presentation of pediatric neuro-acquired immune deficiency syndrome ranges from static (eg, nonprogressive developmental delay) to progressive encephalopathy (eg, acquired microcephaly, pyramidal tract signs, and spasticity). It has been demonstrated that antiretroviral agents can improve or even reverse the course of neurologic impairment in children. These changes have been attributed to various degrees of central nervous system drug penetration. Increasingly, protease inhibitors and combination antiretroviral therapy using reverse transcriptase inhibitors are being used in the treatment of children infected with HIV. The addition of a protease inhibitor to nucleoside analogue therapy has been reported to delay disease progression and prolong life in adults with moderate to advanced HIV disease. No data currently exist on the impact of combination therapy using two nucleoside analogues and a protease inhibitor on neurodevelopmental and neurologic function in children with HIV infection. The following case report presents the effects of combination therapy using ritonavir in a child infected with HIV. CASE REPORT: An 8-year, 2-month-old African-American boy was infected with HIV through vertical transmission. Regular monitoring of the patient's neurodevelopmental status has been conducted as part of his participation in longitudinal research protocols. For the first 51/2 years of life, his neurodevelopmental status was normal, with cognitive functioning as measured by standardized psychometric tools solidly in the average range. Speech and language skills were age-appropriate. Tests of gross and fine motor functioning as well as evaluation of overall neurodevelopmental status suggested normal development. Magnetic resonance imaging (MRI) of the brain was consistently normal. His family reported that adaptive functioning, peer and family relationships, and behavior were all within normal limits. School reports indicated consistently that the patient was performing at age and grade level, with respect to both academic achievement and behavior. Initial concerns regarding the patient's development were expressed by both his family and school at age 6 years, 6 months. These concerns included difficulty with classroom work, decreased attention, word-finding problems, fatigue, staring spells, and loss of strength. His family and school reported a marked loss of skills acquired previously. Results of formal psychological and speech and language evaluation reflected statistically significant drops in test scores from baseline, with both delayed and atypical skills evident. The patient's condition worsened rapidly. Within a few months, he was no longer able to use sentences to communicate. Cognitive testing was attempted, but he was unable to participate because of significant fatigue, limited attention, and inability to communicate verbally. His family described periods of disorientation and confusion, lethargy, and disinterest in age-appropriate activities. He became agitated and overstimulated easily both in small group settings and in crowds. He demonstrated both fine and gross motor impairments. When frustrated, he displayed infantile and autistic-like behavior. MRI with contrast showed diffuse atrophy as well as mild prominence of the ventricles and sulcii compared with baseline assessment. In addition to fatigue and neurologic symptoms, wasting syndrome was diagnosed, with loss of percentiles in both weight and height by age 71/2 years. Low-grade elevation of liver function tests and amylase was noted. Blood cultures for mycobacteria were negative, as were serologic tests for hepatitis. (ABSTRACT TRUN

AIDS Dementia Complex↗
PubMed1998

Parent perceptions of an NICU follow-up clinic.

PURPOSE: To learn how parents perceived their experiences during a visit to an academic center's NICU follow-up clinic and what they would change about the clinic if given the opportunity. DESIGN: A qualitative study utilizing artifact collection, participant observation, and semistructured interviews. SAMPLE: Seven families that went to the clinic. MAIN OUTCOME VARIABLE: What parents did and did not like about the clinic and what they would change about the clinic. RESULTS: Parent concerns included lack of information about the clinic prior to the first appointment, length of wait prior to seeing the physician, preference for more appropriate toys for use during the wait, desire for additional explanations during the exam process, uncertainty about the effects of prematurity on their child's development, and need for more developmental and parenting information.

Aftercare↗
PubMed1997

Neurodevelopmental outcome of extremely low birth weight infants in Maryland.

The survival rate of extremely low birth weight (ELBW; i.e. < 1001 grams) infants has significantly improved in the past 10 years secondary to the numerous advances in neonatology. There have been many favorable reports of the neurodevelopmental outcomes of survivors, but the studies often span several years to collect sufficient number of subjects. This study assesses the outcome of 100 ELBW infants born in Maryland in 1990 and analyzes factors that may have contributed to their outcomes at one year corrected age. Of this group, 72% had no evidence of severe disability (e.g., cerebral palsy (CP) or mental retardation (MR); however, 51% of the children had abnormal or suspect neurological examinations, and 24% had CP. Eighteen percent of the children were more than one standard deviation below the mean cognitively; 30% were below normal for motor abilities, and 33% were below normal for language abilities. Prior to this study, many of these children were not recognized by their primary physician as having any developmental problems. Many of these children were not followed in neonatal intensive care unit (NICU) follow-up programs, and most were not receiving appropriate early intervention services (EIS). Previous studies have associated different neonatal events with the risk of developmental delay. Bronchopulmonary dysplasia (BPD) and periventricular leukomalacia (PVL) accounted for most of the variance of this sample's developmental outcome. Of these 100 ELBW infants, 56 received surfactant. Analysis demonstrated no significant differences in developmental outcomes between those who received surfactant and those who did not. However, those who received rescue surfactant were more likely to acquire a diagnosis of BPD. As demonstrated by this study, ELBW infants are at risk for significant developmental problems. This supports the need for targeted outreach, developmental monitoring, early intervention services, and parent support and education.

Chi-Square Distribution↗
PubMed1994

CAT/CLAMS. A tool for the pediatric evaluation of infants and young children with developmental delay. Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale.

The American Academy of Pediatrics recommends regular developmental screening as a part of routine child health supervision. However, the pediatrician has a limited number of tools available to further evaluate a child who is found to be suspect or abnormal on a developmental screening test. The Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) was therefore developed to provide pediatricians with a technique to assess infants and toddlers with suspected developmental delay. The CAT/CLAMS demonstrated strong psychometric properties. Concurrent validity with the Bayley Scales of Infant Development (BSID) was demonstrated in 43 children ages 12 to 19 months who were tested on three occasions with both instruments (correlation coefficient ranging between 0.63 and 0.87; P < .001). Predictive validity 6 and 12 months later was also demonstrated in this population with correlation coefficients ranging between 0.73 and 0.77, significant at the P = .001 level. Utilizing the CAT/CLAMS as part of the pediatrician's evaluation of children with developmental concerns would allow the pediatrician to compare language and nonlanguage problem-solving abilities and, therefore, aid in diagnosis and appropriate referral.

Developmental Disabilities↗
PubMed1994

Neurodevelopment in pediatric HIV infection. The use of CAT/CLAMS. Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale.

Pediatric neuro-AIDS may be the first clinical manifestation of HIV infection in children born to HIV-infected mothers. As part of the neurodevelopmental examination of children, the Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) was investigated as a tool for pediatricians to use to monitor the development of children at risk for HIV infection. The CAT/CLAMS was found to detect neurodevelopmental differences between HIV-infected and uninfected children at 12 and 18 months of age. Good correlations were found between the CAT/CLAMS and concurrently administered Bayley Scales of Infant Development. These findings suggest that the CAT/CLAMS should be considered as a part of the neurodevelopmental examination of children at risk for pediatric neuro-AIDS.

Acquired Immunodeficiency Syndrome↗
PubMed1988

The effects of physical therapy on cerebral palsy. A controlled trial in infants with spastic diplegia.

Legislatively mandated programs for early intervention on behalf of handicapped infants often stipulate the inclusion of physical therapy as a major component of treatment for cerebral palsy. To evaluate the effects of physical therapy, we randomly assigned 48 infants (12 to 19 months of age) with mild to severe spastic diplegia to receive either 12 months of physical therapy (Group A) or 6 months of physical therapy preceded by 6 months of infant stimulation (Group B). The infant-stimulation program included motor, sensory, language, and cognitive activities of increasing complexity. Masked outcome assessment was performed after both 6 and 12 months of therapy to evaluate motor quotient, motor ability, and mental quotient. After six months, the infants in Group A had a lower mean motor quotient than those in Group B (49.1 vs. 58.1, P = 0.02) and were less likely to walk (12 vs. 35 percent, P = 0.07). These differences persisted after 12 months of therapy (47.9 vs. 63.3, P less than 0.01, and 36 vs. 73 percent, P = 0.01, respectively). We noted no significant differences between the groups in the incidence of contractures or the need for bracing or orthopedic surgery. Group A also had a lower mean mental quotient than Group B after six months of therapy (65.6 vs. 75.5, P = 0.05). The routine use of physical therapy in infants with spastic diplegia offered no short-term advantage over infant stimulation. Because of the limited scope of the trial, our conclusions favoring infant stimulation are preliminary. The results suggest that further study of the effects of both physical therapy and infant stimulation is indicated.

Cerebral Palsy↗
PubMed1986

The Clinical Linguistic and Auditory Milestone Scale (CLAMS). Identification of cognitive defects in motor-delayed children.

The Clinical Linguistic and Auditory Milestone Scale (CLAMS) and Bayley Scales of Infant Development (BSID) were independently administered to 43 children with mild-to-moderate motor delay at 15, 21, and 27 months of age. Highly significant correlations were noted for each examination. Sex, race, and age at time of examination did not significantly influence the relationship between a CLAMS quotient and a Bayley ratio quotient (BRQ). On the first examination gestational age exerted an effect that carried over to the total population. The initial CLAMS quotient also correlated with the results of the CLAMS and BSID administered 12 months later. The CLAMS identified children with a delayed BRQ (less than 70) as follows: sensitivity, 0.66; specificity, 0.79; predictive value of a positive test, 0.80; and predictive value of a negative test, 0.65. The CLAMS provides the pediatrician with a language assessment instrument that adequately detects cognitive deficits in motor-delayed children.

Child Language↗
PubMed1986

Neurologic outcome in premature infants with transient asymptomatic hyperammonemia.

We studied the short-term and long-term effects of transient asymptomatic neonatal hyperammonemia on neurologic function in 21 preterm infants with normal ammonium levels and 25 with hyperammonemia (range 40 to 72 mumol/L) during the first weeks of life. The hyperammonemic infants were prospectively randomized to treatment with orally administered arginine free base 1 to 2 mmol/kg/day for 2 months (n = 13) or to a no-treatment control group (n = 12). Cortical function was assessed by auditory response and habituation during the first month of life. An auditory response was shown by 64% of the hyperammonemic infants and 43% of the normoammonemic infants (P not significant). Plasma ammonium levels at the time of examination bore no consistent relationship to whether an infant responded to an auditory stimulus. Number of trials to reach auditory habituation was also not different, and plasma ammonium level did not correlate with the presence or absence of habituation. IQ testing at 6, 12, 18, and 30 months showed no significant differences between groups. Early plasma ammonium levels did not have an effect on 30-month IQ scores. These findings suggest that transient asymptomatic hyperammonemia in premature infants is not associated with short-term or long-term neurologic deficits through 30 months of age. This study does not support the need for treatment of transient asymptomatic hyperammonemia in the premature infant.

Acoustic Stimulation↗
PubMed1986

Clinical linguistic and auditory milestone scale: prediction of cognition in infancy.

At each well-child examination between birth and two years, parents of 448 infants were questioned about their child's age at attainment of 25 linguistic and auditory milestones. Parental reports were compared with the results of independently administered Bayley Mental Developmental Index (MDI) at one year of age. Parental recall of information was high, ranging from 70 to 99 per cent for 21 of the 25 milestones. The milestone performance of infants with normal MDI scores showed an orderly, sequential progression of expressive and receptive language. Across the entire population studied, the correlation between milestone attainment and MDI was statistically significant for 24 of the 25 milestones, and later attainment of milestones correlated with lower MDI. As a group, 'delayed' infants (MDI less than 68) attained milestones significantly later than 'average' infants (MDI 85 to 116) for 20 of 25 items. Attention to linguistic and auditory milestones early in infancy can contribute to the early detection and diagnosis of mental retardation and disorders of communication.

Auditory Perception↗
PubMed1985

Normal gross motor development: the influences of race, sex and socio-economic status.

The ages at attainment of 12 gross motor milestones were obtained prospectively during well-baby visits in the first two years of life for 381 children. All had been born at term and were judged to be normal at one year. A longitudinal analysis, using an index summarizing each child's progress for eight selected milestones, is reported for the 284 children for whom data were complete. A high percentage of parents were able to report the age at attaining milestones with an acceptable degree of variability. The children attained milestones at earlier ages than traditionally reported. There were only minor sex differences in age at attainment, but black children attained milestones earlier than white children.

Analysis of Variance↗
PubMed1985

Cognitive-motor interactions. The relationship of infant gross motor attainment to IQ at 3 years.

The relationship of gross motor development to later cognitive status was assessed by comparing the ages of attainment of four early milestones to later performance on the Stanford Binet. The ages of rolling supine to prone, sitting alone, crawling, and walking were collected in a prospective fashion via parental report for 213 Caucasian children. Stanford Binet IQ was measured at 3 years. Significant but low-order correlations were noted for age of milestone and Stanford Binet IQ. Stratifying the sample by IQ standard deviation groups revealed significant relationships, but this was largely the result of the difference between the extreme groups (117 vs. 85). Children with earlier ages of milestone attainment did not have higher IQs on average. The association of gross motor development and cognition is not strong enough to allow the use of one to predict the other.

Child Development↗
PubMed1984

Arginine-responsive asymptomatic hyperammonemia in the premature infant.

We found that more than 50% of premature infants have elevated plasma ammonium levels during the first 2 months of life. Ammonium levels were twice normal and were unaccompanied by clinical symptoms of vomiting or lethargy. Ten of these infants were given supplements of arginine (1 to 2 mmol/kg/day PO) for 1 to 2 weeks preceded and followed by control periods. In each infant, plasma ammonium levels fell significantly within 2 days of start of arginine supplementation, and increased once arginine was discontinued. We studied 59 additional premature infants, of whom 26 had normal ammonium levels and 33 were hyperammonemic. Plasma arginine and ornithine levels were significantly lower in the hyperammonemic group, but there was no difference in urinary excretion of arginine or ornithine between groups. Half of the hyperammonemic infants received arginine supplementation between 2 and 8 weeks of age. Plasma ammonium levels in the arginine group was 33 + 1 mumol/L., compared to 45 + 2 mumol/L in the untreated group. Follow-up at 18 months of age showed similar IQ scores in all groups, suggesting that significant neurologic deficits do not result from this transient metabolic defect. The mechanism of the hyperammonemia is unclear.

Ammonia↗
PubMed1984

Primitive reflex profile: a quantitation of primitive reflexes in infancy.

This report describes quantitative standardization data on nine primitive reflexes for a cohort of 381 normal infants evaluated longitudinally at each visit between birth and two years of age. Normality was confirmed by the use of the Bayley Scales of Infant Development at one year of age. The standardization of this new examination technique complements the traditional infant neurological examination and may allow primitive reflexes to become a useful adjunct to the prediction of motor disability in early infancy.

Brain Damage, Chronic↗
PubMed1984

Issues in the early identification of specific learning disability.

Currently the diagnosis of Specific Learning Disability (SLD) requires the demonstration of academic underachievement relative to cognitive potential. However, if the focus is shifted from academic underachievement to the detection of the deviant neurologic substrate, then the potential exists for diagnosing SLD prior to school. Circumstantial evidence from a variety of sources--studies of historical risk, the newborn examination, assessment of newborn behaviors, combination of newborn and subsequent examination, retrospective assessment of early development in SLD children, and aspects of infant development (motor or language) and SLD-suggests that the neurologic substrate for SLD can be identified in infancy. Early identification of SLD will permit early intervention when indicated, aid the assessment of therapeutic efficacy, and facilitate the evaluation of other interventions (e.g., neonatal care).

Child↗
PubMed1982

A prospective study of three postural reactions.

In order to assess the evolution of postural reactions in the prone position, a group of 149 normal infants were followed from birth to two years of age. The Landau reflex was present in 44 per cent of two-month-old infants, and in 95 per cent at four months. The tonic labyrinthine response (grades 2 to 4) was seen in 80 per cent of infants at two weeks, with a marked diminution by the age of 24 months. In contrast, the symmetrical tonic neck reflex was detected in fewer than 30 per cent of the infants: the maximum prevalence was at four to six months of age. These findings are consistent with the hypothesis that the Landau is an early righting reflex which emerges after, and is independent of, the tonic labyrinthine response in prone and the symmetrical tonic neck reflex.

Female↗
PubMed1982

Motor functions: associated primitive reflex profiles.

The results of reflex/motor activity interactions in 177 normal infants are evaluated. The asymmetrical tonic neck reflex, tonic labyrinthine reflex-supine, and Moro reflexes were assessed for each child at birth and at intervals up to 12 months. Ages of rolling prone to supine, rolling supine to prone, and sitting alone were elicited from parents. The effects of the primitive reflexes on early motor activity were assessed, and statistically significant correlations were demonstrated between decreased reflex activity and the emergence of motor milestones. The distinctive association of reflex activity with motor function suggests the interaction of several reflexes (a primitive reflex profile) rather than the influence of isolated reflex activity. Such patterns support the hypothesis that decreasing primitive reflex activity is associated with the onset of volitional motor activity in normal infants.

Developmental Disabilities↗