Cytomegalovirus Viremia Predicts Postdischarge Mortality in Kenyan HIV-Exposed Uninfected Children

BACKGROUND

Cytomegalovirus (CMV) viremia is associated with mortality in severely ill immunocompetent adults and hospitalized children with HIV (CWH). We measured CMV viremia in HIV-exposed and -unexposed Kenyan children aged 1-59 months discharged from hospital and determined its relationship with postdischarge mortality.

METHODS

CMV DNA levels were measured in plasma from 1024 children (97 of which were HIV exposed uninfected [HEU], and 15 CWH). Poisson and Cox proportional hazards regression models were used to identify correlates of CMV viremia ≥ 1000 IU/mL 
and estimate associations with 6-month mortality, respectively.

RESULTS

CMV viremia was detected in 31% of children, with levels ≥ 1000 IU/mL in 5.8%. HIV infection, age < 2 years, breastfeeding, and midupper arm circumference < 12.5 cm were associated with CMV viremia ≥ 1000 IU/mL. Among HEU children, CMV ≥ 1000 IU/mL (hazard ratio [HR] = 32.0; 95% confidence interval [CI], 2.9-354.0; P = .005) and each 1-log increase in CMV viral load (HR = 5.04; 95% CI, 1.7-14.6; P = .003) were associated with increased risk of mortality. CMV viremia was not significantly associated with mortality in HIV-unexposed children.

CONCLUSIONS

CMV levels at hospital postdischarge predict increased risk of 6-month mortality in Kenyan HEU children. CMV suppression may be a novel target to reduce mortality in HEU children.

CLINICAL TRIAL REGISTRATION

NCT02414399.

Formoterol (OXIS) Turbuhaler as a rescue therapy compared with salbutamol pMDI plus spacer in patients with acute severe asthma

Formoterol has a similar onset of effect to salbutamol but a prolonged duration of action. However, the relative efficacy of the two drugs in acute severe asthma is not known. This double-blind, double-dummy study compared the safety and efficacy of the maximum recommended daily dose of formoterol and a predicted equivalent dose of salbutamol in 88 patients presenting to the emergency department with acute severe asthma. Patients were randomized to formoterol 54 microg via Turbuhaler or salbutamol 2400 microg via pressurized metered dose inhaler (pMDI) plus spacer in three equal doses over 1 h. Following the full dose, mean FEV1 at 75 min increased by 37% for formoterol and 28% for salbutamol (P = 0.18). The maximum increase in FEV1 over 4 h was significantly greater with formoterol compared with salbutamol (51% vs. 36%, respectively P < 0.05) and formoterol was as effective as salbutamol at improving symptoms and wellbeing. Both treatments were well tolerated. Formoterol caused a greater decrease in serum potassium (difference -0.2 mmol/l). In severe acute asthma, bronchodilator therapy with high-dose (54 microg) formoterol Turbuhaler provided equally rapid improvements in lung function of greater magnitude over 4 h than high-dose (2400 microg) salbutamol pMDI plus spacer.

Safety of formoterol Turbuhaler at cumulative dose of 90 microg in patients with acute bronchial obstruction

This study compared the safety of formoterol (Oxis Turbuhaler; 90 microg delivered dose; 120 microg metered dose) with terbutaline (Bricanyl Turbuhaler; 10 mg), in patients with acute bronchoconstriction. Forty-eight patients (31 females) with a mean age of 45 yrs, were randomized into two parallel groups (double-blind design). Mean baseline forced expiratory volume in one second (FEV1) was 0.98 L (33% of predicted normal). Study drugs were administered on six occasions during 3 h (formoterol 4.5 microg or terbutaline 0.5 mg x inhalation(-1), 20 inhalations). Patients received intravenous prednisolone after 1.5 h and oxygen during the first 3 h. Pulse rate, serum potassium, 12-lead electrocardiogram (ECG), Holter ECG, arterial blood gases and FEV1 were assessed during 12 h after the first dose. Four patients (one formoterol, three terbutaline) discontinued. The 12-h mean values of serum potassium decreased from 4.02 to 3.89 mmol x L(-1) for formoterol and from 4.22 to 3.76 mmol x L(-1) for terbutaline. Mean 12-h pulse rate was significantly (p<0.01) higher in the terbutaline group (101.7 beats per minute (bpm)) than in the formoterol group (93.5 bpm). No individual patient value was considered clinically important or alarming. FEV1 improved in both groups but with no statistically significant difference between treatments. Oxis Turbuhaler (90 microg) was at least as safe and well tolerated as terbutaline (10 mg) [DOSAGE ERROR CORRECTED] in patients with acute bronchoconstriction.

Training of head control in the sitting and semi-prone positions

The purpose of this study was to compare the semi-prone (SP) and sitting (SIT) training positions with respect to head control in children with cerebral palsy, before and after 5 weeks biofeedback training using a head position trainer (HPT). Four children were randomly assigned to each of two training groups: (a) SP on a prone board inclined 45 degrees above the horizontal and (b) SIT in their personal wheelchair and orthotic device. The HPT, secured to the child's head, controlled a video-cassette player, turning it off when the head deviated beyond 25 degrees from the vertical (termed an error). The time in error and the number of errors during test periods of 3 minutes, without feedback and completed in both the SP and the SIT positions, were determined immediately before and after, and at 16 weeks after training. The SIT trained group performed significantly better immediately post-training in three of four comparisons (P < 0.01), but the groups performed similarly in the other eight comparisons--four immediately pre-training and four at 16 weeks post-training (P > 0.05). Post-training scores for the total group (n = 8) were significantly improved over pre-training scores, regardless of the test position or the criterion measurement (P < 0.05). Biofeedback training with a HPT can be effective in either the SIT or the SP positions, with improvement lasting at least 16 weeks after training is discontinued.