Identifying the behavioural phenotype in Fetal Alcohol Spectrum Disorder: sensitivity, specificity and screening potential

BACKGROUND

In most cases of Fetal Alcohol Spectrum Disorder (FASD), the pathognomonic facial features are absent making diagnosis challenging, if not impossible, particularly when no history of maternal drinking is available. Also because FASD is often comorbid with Attention Deficit Hyperactivity Disorder (ADHD), children with FASD are frequently improperly diagnosed and receive the wrong treatment. Since access to psychological testing is typically limited or non-existent in remote areas, other diagnostic methods are needed to provide necessary interventions.

OBJECTIVES

To determine if a characteristic behavioural phenotype distinguishes children with FASD from typically developing children and children with ADHD and use this information to create a screening tool for FASD diagnosis.

METHODS

Parents and caregivers completed the Child Behavior Checklist (CBCL), a well-established standardized tool for evaluating children's behavioural problems. Results from 30 children with Fetal Alcohol Syndrome or Alcohol-Related Neurodevelopmental Disability, 30 children with ADHD, and 30 typically developing healthy children matched for age and socioeconomic status with FASD were analyzed. Based on our previous work, 12 CBCL items that significantly differentiated FASD and control groups were selected for further analyses. Stepwise discriminant function analysis identified behavioural characteristics most strongly differentiating groups and Receiver Operating Characteristics (ROC) curve analyses determined sensitivity and specificity of different item combinations.

RESULTS

Seven items reflecting hyperactivity, inattention, lying and cheating, lack of guilt, and disobedience significantly differentiated children with FASD from controls. ROC analyses showed scores of 6 or higher on these items differentiated groups with a sensitivity of 86%, specificity of 82%. For FASD and ADHD, two combinations of items significantly differentiated groups with high sensitivity and specificity (i) no guilt, cruelty, and acts young (sensitivity = 70%; specificity = 80% (ii) acts young, cruelty, no guilt, lying or cheating, steals from home, and steals outside (sensitivity = 81%; specificity = 72%). These items were used to construct a potential FASD screening tool.

CONCLUSIONS

Our findings identifying the behavioural characteristics differentiating children with FASD from typically developing children or children with ADHD have the potential for development of an empirically derived tool for FASD tool to be used in remote areas where psychological services are not readily available. This technique may speed up diagnosis and intervention for children without ready access to formal assessments.

The Toronto experience in diagnosing alcohol-related neurodevelopmental disorder: a unique profile of deficits and assets

BACKGROUND

Fetal alcohol syndrome (FAS), which involves the triad of features reflecting facial dysmorphology, growth retardation and intellectual impairments, encompasses a relatively small proportion of the children affected prenatally by alcohol. Unfortunately, in the absence of facial dysmorphology, the diagnosis is difficult in the majority of children, who are considered to have alcohol-related neurodevelopmental disorder (ARND). Because accepted clinical methods are not pathognomonic, a novel profile approach was used to examine neuropsychological abilities and disabilities to identify children with ARND who do not meet the diagnostic criteria of FAS.

OBJECTIVE

To establish a set of criteria, to be validated in future studies, for characterizing the neuropsychological profile of children with ARND. By describing the procedures at this preliminary stage of our work, the goal is to draw attention to this neglected topic and to suggest a model that can be replicated and validated by others, and to provide the first systematic clinical report on diagnosing ARND in Canada.

PROCEDURES

On the basis of the literature, parents' descriptions and the authors' own experience with ARND, a profile of neuropsychological characteristics, including both deficits and assets, that are associated with prenatal alcohol exposure was hypothesized. A group of children was then evaluated, mostly adoptees or children in foster care, who were referred for learning and behavioural problems potentially associated with gestational exposure. Their results were submitted to a profile analysis by comparing their deficits and assets according to a list describing a hypothetical ARND profile to determine whether each child fit or did not fit the ARND profile. Groups were compared for background characteristics, FAS symptomatology, and results on specific neuropsychological and behavioural tests. Finally, the characteristics most strongly differentiating the two groups were identified.

SETTING

Hospital-based outpatient program.

PARTICIPANTS

Fifty-two children aged four to 18 years who were referred for a diagnostic assessment related to suspected or known prenatal alcohol exposure.

OUTCOME MEASURES

Each child's assessment results were compared against a list of 21 deficits and six assets by two independent raters. Children with an average of more than 60% deficits and 50% assets were considered to have ARND, while the remainder were not.

RESULTS

Twenty-eight children (54%) were assigned to the ARND group and 24 to the non-ARND group. The groups did not differ in physical features or home background characteristics, with the exception of higher parental intelligence quotient in the non-ARND group. The ARND group was more likely to have repeated a grade or received special education and scored lower on standardized measures of intelligence, language and memory abilities. Frequency of behaviour or social problems were equivalent in both groups.

CONCLUSIONS

A profile approach used to identify children with ARND discriminates problems in neuropsychological but not behavioural domains. Because elevated scores on behavioural tasks in both ARND and non-ARND groups were clinically significant, more research is needed to identify what behavioural problems are unique to children with ARND compared with other clinic-referred children.

Neurodevelopment of adopted children exposed in utero to cocaine: the Toronto Adoption Study

BACKGROUND

Published studies of children's neurodevelopment after in utero exposure to cocaine have not separated intrauterine from postnatal environmental effects as cocaine-using mothers cluster in low socioeconomic classes and have other risk factors.

METHODS

To overcome this limitation, a study was done to assess physical and neurodevelopmental characteristics of 52 children: 26 were adopted by parents who sought counselling in the Motherisk Program at the University of Toronto for prenatal cocaine exposure, and 26 were controls matched for maternal intelligence quotient (IQ), socioeconomic status and gestational age.

MAIN OUTCOME MEASURES

Head circumference, McCarthy General Cognitive Index (GCI) score, language performance and temperament tests.

RESULTS

The children in the study group had smaller head circumferences (34th versus 54th percentiles p = 0.009), lower McCarthy GCI scores (102.8 versus 114.2, p = 0.02), poorer receptive and expressive language performance on the Reynell test, and higher activity levels, less persistence and increased distractibility on temperament tests. On multivariate analysis, cocaine exposure was significantly (p = 0.001) associated with lower IQ and poorer language development independent of intrauterine growth retardation and other potential confounders.

INTERPRETATION

By controlling for postnatal environmental factors, this adoption study documents intrauterine developmental risks associated with cocaine exposure. Follow-up into school years is warranted to evaluate the extent of these effects.

Piracetam therapy does not enhance cognitive functioning in children with down syndrome

BACKGROUND

Piracetam is widely used as a purported means of improving cognitive function in children with Down syndrome. Its efficacy, however, has not been rigorously assessed.

OBJECTIVE

To determine whether 4 months of piracetam therapy (80-100 mg/kg per day) enhances cognitive function in children with Down syndrome.

DESIGN

A randomized, double-blind, placebo-controlled crossover study.

PARTICIPANTS AND METHODS

Twenty-five children with Down syndrome (aged 6.5-13 years) and their caregivers participated. After undergoing a baseline cognitive assessment, children were randomly assigned to 1 of 2 treatment groups: piracetam-placebo or placebo-piracetam.

MAIN OUTCOME MEASURE

The difference in performance while taking piracetam vs while taking placebo on tests assessing a wide range of cognitive functions, including attention, learning, and memory.

RESULTS

Eighteen children completed the study, 4 withdrew, and 3 were excluded at baseline. Piracetam therapy did not significantly improve cognitive performance over placebo use but was associated with central nervous system stimulatory effects in 7 children: aggressiveness (n = 4), agitation or irritability (n = 2), sexual arousal (n = 2), poor sleep (n = 1), and decreased appetite (n = 1).

CONCLUSION

Piracetam therapy did not enhance cognition or behavior but was associated with adverse effects.

Comparison of the pharmacokinetics of fosinoprilat with enalaprilat and lisinopril in patients with congestive heart failure and chronic renal insufficiency

AIMS

To compare the serum pharmacokinetics of fosinoprilat with enalaprilat and lisinopril after 1 and 10 days of dosing with fosinopril, enalapril and lisinopril.

METHODS

Patients with congestive heart failure (CHF, NYHA Class II-IV) and chronic renal insufficiency (creatinine clearance </=30 ml min-1 ) were randomized to receive fosinopril, enalapril or lisinopril in two parallel-group studies. In the first study 24 patients were treated with 10 mg fosinopril (n=12 patients) or 2.5 mg enalapril (n=12) every morning for 10 consecutive days. In the second study 31 patients were treated with 10 mg fosinopril (n=16 patients) or 5 mg lisinopril (n=15) every morning for 10 consecutive days. Samples of blood were collected for determination of pharmacokinetic parameters. The area under the curve (AUC) between the first and last days of treatment and the accumulation index (AI) were the primary outcome measures.

RESULTS

All three angiotensin converting enzyme (ACE) inhibitors exhibited a significant increase in AUC between the first and last days of treatment in both studies. The difference between the AI for fosinoprilat (1.41) and enalaprilat (1.96) was statistically significant (95% CI: 1.05, 1.84). Similarly, the difference between the AI for fosinoprilat (1.21) and lisinopril (2.76) was statistically significant (95% CI: 1.85, 2.69). All three ACE inhibitors completely inhibited serum ACE for 24 h. All treatments were well tolerated.

CONCLUSIONS

Fosinoprilat exhibits significantly less accumulation than enalaprilat or lisinopril in patients with CHF and renal insufficiency, most probably because fosinoprilat is eliminated by both the kidney and liver, and increased hepatic elimination can compensate for reduced renal clearance in patients with kidney dysfunction.

Long-term neurodevelopmental risks in children exposed in utero to cocaine. The Toronto Adoption Study

Children exposed in utero to cocaine are at risk for long-term neurobehavioral damage not just because of the drug itself; but also because of clustering of other health determinants, including low socioeconomic status, low maternal education, and maternal addiction, to mention a few. One methodologic approach to separate the direct neurotoxic effects of cocaine from these synergistic insults is to follow up a cohort of children exposed in utero to cocaine and given up for adoption to middle-upper class families. The Toronto Adoption Study, supported by Health Canada, has proven the direct neurotoxic effects of cocaine on IQ and language. These effects are mild to moderate as compared to those measured in children exposed in utero to cocaine and reared by their natural mothers.

Myoglobinuric acute renal failure in the rat: a role for acidosis?

Myoglobin induces renal injury by mechanisms that remain incompletely defined. Acidosis has been suggested as an important factor in myoglobinuric renal failure, and urine alkalization is routinely recommended for its prevention. We tested this hypothesis by exploring the effects of acid-base balance upon myoglobin nephrotoxicity in vivo and in vitro. In isolated rat kidneys at normal pH, myoglobin at concentrations of 25-250 mg/dl minimally affected renal perfusion flow, glomerular filtration rate (GFR) and tubular sodium reabsorption (TRNa). By contrast, at pH 7.1 myoglobin induced vasoconstriction, reduced GFR and TRNa and increased hypoxic injury to medullary thick ascending limbs. These changes were largely reproduced by perfusing kidneys with hematin, suggesting its release from myoglobin in acidosis. Chronic alkalosis or acidosis was induced in rats by supplementing drinking water with 0.28 M NaHCO3 or NH4Cl, respectively. Acute renal failure, produced in control animals by myoglobin infusion (38 mg/100 g body weight), was comparably prevented by both chronic alkalosis and acidosis. Acute intravenous or oral acid load provided similar protection. Thus, although acidosis exacerbates myoglobin toxicity in isolated perfused kidneys, acute or chronic exogenous acid load prevents renal damage in vivo. This may underscore the protective properties of solute load, a consequence of preconditioning, and suggests that, in the crush syndrome, endogenous acidosis rather than being an independent risk factor is a marker of tissue hypoperfusion and organism susceptibility to myoglobin renal toxicity.

Enhanced deposition of predominantly type I collagen in myocardial disease

The myocardium consists of a muscle fibre array surrounded and interspersed by a network of connective tissue, principally collagen, which maintains the functional integrity of the heart. Changes in collagen composition may therefore contribute to altered ventricular function. Collagen composition was examined in cardiac tissue from 15 patients undergoing orthotopic cardiac transplantation. Of these, 10 had severely impaired left ventricular function due to coronary artery disease. The remaining five had dilated cardiomyopathy. Normal heart tissue was taken at autopsy from 25 patients who died of causes unrelated to cardiovascular disease. Left ventricular collagen concentration, estimated from hydroxyproline levels, increased from 48.6 +/- 4.1 mg/g dry weight of tissue in the control group to 95.3 +/- 9.7 mg/g (P less than 0.01) in patients with dilated cardiomyopathy and to 63.5 +/- 9.8 mg/g in the coronary artery disease group. This increase was attributable to an increase in absolute concentrations of both type I and III collagen, determined by separation of cyanogen bromide peptides by sodium dodecyl sulphate polyacrylamide gel electrophoresis. However, there was a significant decrease in the proportion of type III collagen (compared with type I plus III) from 41.8 +/- 1.1% in controls, to 34.6 +/- 1.5% (P less than 0.01) in the coronary artery disease group and 35.8 +/- 2.8% (P less than 0.05) in the dilated cardiomyopathy group. These results suggest that excessive collagen production, with a preponderance of type I, occurs in these forms of myocardial disease, indicative of a remodelling of the collagen matrix, which, by increasing passive myocardial stiffness may contribute to impaired heart function seen in these groups of patients.

Effects of prenatal cocaine exposure on behavior during the early postnatal period

Offspring of Sprague-Dawley dams injected SC with 40 mg/kg/3 cc cocaine HCl daily from gestational days 8-20, pair-fed dams injected with the vehicle alone and nontreated control dams were examined behaviorally during the early postnatal period. No significant differences were observed among the treatment conditions in maternal weight gain during pregnancy, duration of pregnancy, or number of live male and female pups/litter. Offspring body weights at birth and weaning, physical maturation and reflex development were not significantly affected by prenatal cocaine exposure. In contrast, neonates exposed prenatally to cocaine were observed to exhibit significant deficits in learning of an odor/milk association that nontreated offspring learned and retained for a 24 hr period. On postnatal day 12, cocaine offspring exhibited an increase in locomotor activity and attenuated wall climbing precipitated by footshock, in the absence of any alteration in sensitivity to footshock. Given that wall climbing has been previously shown to be strongly related to levels of catecholamine activity at this age, these data suggest the possibility that there may be some attenuation in catecholaminergic function in pups exposed gestationally to cocaine. The results of this study provide evidence that prenatal cocaine exposure may have an impact upon behavioral and cognitive function even during the early postnatal period. More work is needed to fully characterize the range of alterations observed and the neural mechanisms underlying these early exposure effects.

Reliability and concurrent relations between the teacher version of the Child Behavior Profile and the Conners Revised Teacher Rating Scale

A total of 104 disturbed boys aged 6-11 were assessed with the teacher version of the Child Behavior Profile and the Conners Revised Teacher Rating Scale (TRS). A subsample of 55 boys were reassessed with both measures at an interval of 1 week. For the teacher Profile, test-retest correlations averaged r = .87 for eight behavior problem scales and r = .91 for four adaptive functioning scales. Reliabilities were slightly higher for Externalizing scales (average r = .91) than for Internalizing scales (r = .80). Reliabilities averaged .94 for the Revised TRS. Correlations between the two measures indicated a strong correspondence between the three Externalizing scales of the Profile and the factor-based TRS scales. Specifically, Profile scales labeled Inattentive, Nervous-Overactive, and Aggressive correlated highly (p less than .001) with TRS scales labeled Inattentive-Passive, Hyperactivity, and Conduct Problem, respectively. The Conners Hyperkinesis Index correlated highly with all three Externalizing scales of the Profile, particularly Aggressive (r = .82). Overall, these results support the reliability and concurrent validity of both measures.

Effect of rebreathing on psychomotor skills when wearing integral crash helmets

Nine volunteer subjects underwent psychomotor testing when wearing an integral crash helmet in a variety of conditions which lead to rebreathing. There was a wide individual variation in the extent of rebreathing. In the worst conditions the minimum inspired carbon dioxide tension (PICO2) increased to 2.6 kPa. The psychomotor test was a tracking test based on a microcomputer. There was a significant deterioration in the ability to perform the test when the helmet was worn with the visor down and restricted airflow into the helmet (P = less than 0.05). In those tests when the minimum PICO2 exceeded 0.5 kPa the decrease in performance was more highly statistically significant (p = less than 0.005). Rebreathing wearing integral crash helmets results in a variable impairment in the subjects' ability to perform a tracking test. We recommend that the maximum level of CO2 retention inside integral crash helmets should not exceed 0.5 kPa minimum PICO2.

Percutaneous antegrade urethral catheterization of the traumatized urethra

A percutaneous approach for urethral catheterization and dilatation is described. This simple technique, which uses commercially available angiographic catheters, guide wires, and a dilator set, is effective, safe, and necessary when conventional retrograde dilatation fails.

Rebreathing in a subject wearing an integral crash helmet

The respired air of a volunteer was analysed while he was wearing a variety of integral crash helmets. Observations were made with and without a protective balaclava, bib or scarf, or both. Rebreathing occurred and the peak inspired oxygen tension fell as low as 16.0 kPa (120 mm Hg) with a minimum inspired carbon dioxide of 2.1 KPa (16.0 mm Hg). Accessories worn or attached to the helmet which restrict airflow into the helmet should not be used. Attention should be paid to the "air conditioning" of helmets when worn with flameproof balaclavas and bibs.

A study of intracuff pressure measurements, trends and behaviour in patients during prolonged periods of tracheal intubation

Intracuff pressure (c.p.) was measured continuously in 12 patients during prolonged periods of tracheal intubation. High residual volume--low pressure (floppy) and low residual volume--high pressure (conventional) cuffs were studied. The mean baseline c.p. at minimal occluding pressure was significantly smaller in floppy cuffs than in conventional cuffs. With coughing, the peak pressures in both cuff types were much greater than the baseline pressures but did not differ significantly from each other. On the basis of our observations, we recommend a simplification of the test methods for cuffs and tube collapse. We believe universal testing to 300 mm Hg (40 kPa) to be reasonable and to incorporate a realistic safety factor. Intracuff pressure tends to diminish with time, but there is a poor correlation between the rate of pressure decrease and elapsed time. As this decrease is not accurately predictable, gas should be added to the cuff as required, rather than at intervals. Other features of cuff behaviour are discussed and suggestions made to explain some anomalies occasionally observed in the cuff pressure behaviour pattern.

Agent-specific filling devices. An evaluation of two prototypes

Two prototype agent-specific devices have been tested and neither in its present form is ideal. Filling of vaporisers may be delegated to inexperienced persons but the devices tested do not ensure that vaporisers can only be filled with the correct agent. Significant atmospheric pollution with the volatile anaesthetic agent may occur at the time of filling. At present, the devices are limited to three agents, enflurane, halothane and methoxyflurane.

A simplified technique for cannulation of the jugular bulb

A method of jugular bulb cannulation is discussed which is quick and easy to perform, ensures accurate placement of the catheter tip and causes minimal discomfort to the patient. Advantages of this technique are discussed.

Disturbances of pulmonary function in patients with fat embolism

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