1488

only rarely been previously associated with enterococcal superinfection.2 Our data suggest that patients treated with imipenem, especially those receiving intensive chemotherapy, should be monitored carefully for the development of superinfection by imipenem-resistant enterococci.

has

JAMES W. GRAY STEPHEN J. PEDLER JENNIFER KERNAHAN ANDREW D. J. PEARSON

Departments of Microbiology and Child Health, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK

ALAN W. CRAFT

1. Hauer

C, Urban C, Slavc I, Gamillscheg A, Lackner H. Imipenem-antibiotic monotherapy in juvenile cancer patients with neutropenia. Pediatr Haematol Oncol 1990; 7: 229-41. R, Yung R, Chiu E, et al. Ceftazidime versus imipenem-cilastatin as initial monotherapy for febrile neutropenic patients. Antimicrob Agents Chemother 1990;

2. Liang

34: 1336-41.

Gray JW, Stewart D, Pedler SJ. Species identification and antibiotic susceptibility testing of enterococci isolated from hospitalized patients. Antimicrob Agents Chemother 1991; 35: 1943-45. 4. Murray BE. The life and times of the enterococcus. Clin Microbiol Rev 1990; 3: 46-65. 3.

Simvastatin

use

in children

SiR,—The 1992 report of an expert panel on blood cholesterol in young people1 recommends drug therapy only in children aged 10 years and older when diet therapy has failed after 6 months to 1 year.

And bile acid sequestrants are regarded as the only advisable drug. "Statins" (inhibitors of HMG CoA reductase) are very effective in adults with primary hypercholesterolaemia and side-effects are not frequent. However, we know of no data on their use in children. We describe here the long-term efficacy and safety data (24-36 months) in 32 hypercholesterolaemic children younger than 17 years. The children were included in a compassionate use programme for simvastatin. Male or female young patients were allowed to enter this protocol if their total cholesterol was above 300 mg/dl after diet therapy for 6 months. Children under the age of 10 started at an initial dose of 5 mg once daily. Titration to 10 mg daily after 4 weeks and to 20 mg after another 4 weeks was possible. Older children began on a daily dose of 10 mg, which was increased to 20 mg after 6 weeks and, after an additional 6 weeks, to 40 mg if necessary. The mean dosage was 16 mg once daily (37% received 10 mg, 38% 20 mg, and 25% 40 mg). Monthly efficacy and safety measurements were scheduled during the observation period. 22 young patients were male and 10 were female. The analysis was based only on the 16 patients with a follow-up of at least 24 months. Efficacy data (lipid values) were based on the percentage changes from baseline and changes were analysed by Wilcoxon signed-rank test (two sided p). Lipid values (mg/dl) were: Week

Week

Mean %

change

C=cholesterol, LDL and HDL= low and high density cholesterol, T=tng!ycendes. The LDL/HDL ratio (probably the best indicator ofatherogenic risk) fell by 43%. LDL-cholesterol at week 104 had fallen by 40-60% in 7 patients, by 20-40% in 8, and by 15-20% in 1. Long-term safety and tolerance is a major concern in this young population and special attention has been paid to laboratory safety assessment. At weeks 4, 12, 26, 52, 78, and 104 transaminases, alkaline phosphatase, and creatinine phosphokinase (CPK) were measured. No significant changes were detected. The 1 transaminase increase and 2 CPK increases were transient. Investigators were asked to record the height and weight of their children during the trial. Height data are available for 12 patients and weight for 16. In this period of active growth, the children remained in the growth percentiles they had been in at baseline. The use of simvastatin in hypercholesterolaemic children, together with diet advices, seems to be effective and well tolerated.

Further observations with results are encouraging.

longer follow-up

are

needed but

our

We thank the following for enrolling patients in this protocol: Dr R. Bolome, Dr H. Derweduwen, Dr P. Forget, Dr P. van Crombrugge, and Prof A. Venneulen.

CHU de Tivoli, 7100 La Louviere,

Belgium

Hôpital des Enfants Reine Fabiola, Brussels

Hôpital de Jolimont, La Louviere University Hospital (RUG), Ghent

Cliniques Universitaires St Luc, Brussels

J. DUCOBU D. BRASSEUR

J-M. CHAUDRON J-P. DESLYPERE C. HARVENGT

University Hospital (KUL), Leuven

E. MULS

MSD

M. THOMSON

1.

Belgium,

Brussels

Panel on blood cholesterol levels in children and adolescents. Pediatrics 1992; 89: 525-84.

Report of the Expert

Aluminium exposure in children associated with industrial waste SIR,-Eastwood et all have described two cases of aluminium (Al) intoxication due to the accidental dumping of 20 tonnes of 8% aluminium sulphate solution into a public water supply. They concluded that in certain circumstances people with normal renal function can absorb and retain high concentrations of Al. In agreement with this, we report two cases of Al absorption in children as a consequence of uncontrolled industrial dumping. A factory recycling Al by the melting of paper-backed Al foil and non-ferrous scrap was set up in a rural town 120 km from Barcelona. The waste (50 000 kg of ash in 45 days) was deposited in containers in the open air near the garden of a private house. 3 weeks after the recycling began the owner of the house took his 4-year-old son to the family doctor because of fever and changes in behaviour (apathy, sadness, restlessness, lack of attention). The boy was treated for those symptoms. 2 months later his behaviour was still abnormal and he was taken to a hospital in Barcelona. Physical examination, chest radiography, electrocardiogram, electroencephalogram, and hepatic and renal function tests were normal. On intelligence testing the boy had an IQ of 105 on the Wechsler scale and 88 (low normal) on the Leiter (non-verbal) scale. A computed tomographic scan revealed hypodense lesions in both semioval centres, compatible with ischaemic infarction. A nuclear magnetic resonance scan revealed multiple lesions with necrotic features in the white subcortical matter of both cerebral hemispheres and right basal ganglions, probably secondary to ischaemic infarction. The concentration of Al in the child’s blood 1 month after the recycling process had been stopped was 41 )ig/I (normal < 5). We then measured serum Al in his 14-month-old sister who, although without symptoms, also played in the garden, and in the father found concentrations of 50 and 30 ug/1, respectively. Serum Al was also measured in five children and five adults living in the same location and values were less than 5 pg/1. The ash found in the garden and inside the house contained 19% Al in a dry sample, plus iron 0-3% and barium, copper, chromium, nickel, zinc, and lead (all below 0’02%). The house’s tap-water contained 0-06 mg/1 Al (acceptable values

Simvastatin use in children.

1488 only rarely been previously associated with enterococcal superinfection.2 Our data suggest that patients treated with imipenem, especially those...
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