Assessing psychosocial well-being of adolescents: a systematic review of measuring instruments.

BACKGROUND: The paradigm shift from the clinically deficit-oriented approach to that of educationally strength-based model in assessing adolescents' psychosocial well-being has brought about a recent increase in school-based health promotion and prevention initiatives. This prompted this systematic review of measuring instruments designed to assess psychosocial well-being of children and adolescents. METHODS: Using electronic databases on Academic Search Premier, MEDLINE, PROQUEST, PsycINFO, CINAHL Plus and Psychosocial and Health Instrument, a systematic review of literature of measuring instruments was conducted from their inception to December 2009 using the keywords of child, emotion, assessment, scale and measure. Measuring instruments from selected articles were critically appraised using a predetermined set of quality indicators which guided the rating of the psychometric properties of the instruments into grades of A, B, and C. The constructs of psychosocial well-being from the measuring instruments were categorized into themes. RESULTS: Twenty-nine out of the 908 articles met the inclusion criteria. Seventeen instruments identified from the selected articles were examined using preset quality indicators. In construct building, the themes identified from the strength-based instruments distinguished the construct of psychosocial well-being primarily into the dimensions of personal emotional competency and social functioning. In the ratings of psychometric properties, one instrument was rated 5A, five rated 4A and four rated 3A. For reliability testing, eight measures received grade A when their intraclass correlation is higher than 0.7; whereas only two instruments reported sensitivity and none investigated responsiveness. CONCLUSIONS: Strength-based measures focusing on social emotional behavioural outcomes open up a possibility to link up assessment with promotion of psychosocial well-being, away from clinical settings and into adolescents' homes, schools and community. Future research should focus more on investigating the sensitivity and responsiveness of measuring instruments using longitudinal design in efficacy studies to assess change in adolescents' psychosocial status over extended time.

Improving quality of life of children with cerebral palsy: a systematic review of clinical trials.

OBJECTIVE: To systematically review the impact of different interventions on quality of life (QoL) for children with cerebral palsy. METHODS: English articles were sought from five major English databases from inceptions until March 2010. Keywords used consisted of four components (and their variants): (i) clinical condition: cerebral palsy; (ii) outcome measures: quality of life, well-being; (iii) study design: clinical trials; and (iv) target population: people aged 0-18. RESULTS: Eight studies satisfied the inclusion criteria, all of which are of good to excellent quality (a Jadad score of 4 or above). The Pediatric Evaluation of Disability Inventory, the Pediatric Quality of Life Inventory, the TNO-AZL Children's Health-Related Quality of Life and the Caregiver Priorities and Child Health Index of Life with Disabilities were used to measure QoL. Significant positive results were reported by two studies using medicinal interventions (diazepam and intrathecal baclofen therapy, effect sizes 5.9, 9.1 respectively) and two studies employing motor control approach training (strength training and exercise training, former effect size being 3.8). CONCLUSION: Current review suggests that positive effect was shown in medicinal and motor control interventions on QoL. However, no single interventional approach can demonstrate a consistent positive impact on QoL across different studies. Future studies are recommended to (i) provide a clear definition of QoL, and investigate the relationship between symptoms' severity and QoL; (ii) measure outcome at different time points to capture real effects of interventions; and (iii) make more use of valid outcome instruments, either self-report or parent/caregiver proxy reports.

Transient adhesion of neutrophils to endothelium.

Fluorescently labeled polymorphonuclear leukocytes (PMN) were used to measure adhesion to human umbilical vein endothelial cells (EC) cultured in vitro. Stimulation of PMN with phorbol dibutyrate (PDB), TNF, or C5a caused an increase in adhesion followed by a return to prestimulation levels of adhesion of longer times of incubation. Maximal adhesion of PMN to EC occurred rapidly in response to C5a (5 min) and more slowly with TNF or PDB (15 min). PMN stimulated to adhere with C5a detached from EC by 15 min. PMN from CD11/CD18-deficient patients and PMN incubated with anti-CD18 mAbs failed to bind to EC despite maximal stimulation. Anti-CD11a/CD18 and anti-CD11b/CD18 each partially inhibited adhesion, and a combination of these two reagents completely blocked adhesion. The adhesion we measured was therefore completely dependent on CD11/CD18, and CD11a/CD18 and CD11b/CD18 each contributed to adhesion. Stimuli that enhanced adhesion of PMN to EC also enhanced expression of CD11b/CD18 on the cell surface, but the time course of expression correlated poorly with changes in adhesivity. To determine if changes in the expression of CD11b/CD18 are necessary for the changes in adhesivity, we used enucleate cytoplasts that did not increase expression of CD11b/CD18. Cytoplasts showed a normal rise and fall in adhesivity in response to PDB. We conclude that the transient adhesion of stimulated PMN to naive EC is regulated by changes in the nature of existing CD11/CD18 molecules on the PMN surface. Changes in expression of CD11b/CD18 may contribute to enhancement of adhesivity, but a definite role for this phenomenon has yet to be established.

Endothelial-leukocyte adhesion molecule 1 stimulates the adhesive activity of leukocyte integrin CR3 (CD11b/CD18, Mac-1, alpha m beta 2) on human neutrophils.

Two classes of adhesion molecules have well-defined roles in the attachment of unstimulated polymorphonuclear leukocytes (PMN) to cytokine-treated endothelial cells. Endothelial-leukocyte adhesion molecule 1 (ELAM-1) on endothelial cells interacts with specific carbohydrate residues on the PMN, and the leukocyte integrins (CD18 antigens) on PMN interact with intracellular adhesion molecule 1 and other structures on endothelium. Here we show that these two classes of molecules can act sequentially in an "adhesion cascade". Interaction of PMN with ELAM-1-bearing endothelial cells causes PMN to express enhanced adhesive activity of the integrin CR3 (CD11b/CD18). Expression of ELAM-1 on the cytokine-treated endothelium appears both necessary and sufficient for the stimulation of CR3 activity since blockade of ELAM-1 with mAbs prevents the activation of CR3 by cytokine-treated endothelium, and immobilized recombinant ELAM-1 activates CR3. The ability to activate CR3 is shared by chemattractants, suggesting that ELAM-1 may serve as a "tethered chemattractant." This hypothesis is strengthened by the observation that recombinant soluble ELAM-1 directs movement of PMN in chemotaxis chambers. These results suggest a mechanism by which multiple adhesive molecules may function together in diapedesis. ELAM-1 serves both as an adhesin and as a trigger that recruits the participation of additional adhesion molecules. Our results also suggest that ligands for adhesion molecules may also be "receptors" capable of generating intracellular signals.

Neutrophil-activating protein 1/interleukin 8 stimulates the binding activity of the leukocyte adhesion receptor CD11b/CD18 on human neutrophils.

The cytokine NAP-1/IL-8 is produced by a variety of different cells in response to inflammatory stimuli and elicits several biological responses from PMN. Experiments presented here demonstrate that PMN exposed to NAP-1/IL-8 expressed increased amounts of CD11b/CD18, as well as CD11c/CD18 and CR1, on their cell surface, while expression of Fc gamma RIII and HLA-A,B,C remained essentially unchanged. Increased CD11b/CD18 and CD11c/CD18 appears to correspond with the release of specific granules by NAP-1/IL-8. NAP-1/IL-8 was also a potent stimulator of several of the binding activities of CD11b/CD18. Ligation of EC3bi by CD11b/CD18 was rapidly enhanced by NAP-1/IL-8, but phagocytosis of the ligated particles was not induced by the agonist. In addition, enhanced binding of EC3bi was observed in the absence of an increase in receptor expression as shown with PMN cytoplasts. NAP-1/IL-8 promoted additional adhesive interactions between CD11b/CD18 and the biosynthetic precursor of LPS, lipid IVa, fibrinogen, and endothelial cells, suggesting that NAP-1/IL-8 may promote leukocyte adhesion in vivo that could lead to recruitment of PMN to sites of tissue inflammation.

Validating the Cerebral Palsy Quality of Life for Children (CP QOL-Child) questionnaire for use in Chinese populations.

The purpose of this study was to examine the psychometric properties of the Chinese version of Cerebral Palsy Quality of Life for Children (CP QOL-Child) questionnaire. We performed forward (into Chinese) and backward translation of the CP QOL-Child for: (1) the primary caregiver form (for parents of children with CP aged 4-12 years); and (2) the child self-report form (for children with cerebral palsy aged 9-12 years). Psychometric properties assessed included test-retest reliability, internal consistency, item discrimination, construct validity, and concordance between the forms of questionnaire. The Chinese CP QOL-Child was completed by 145 caregivers and 44 children. Excellent test-retest reliability and internal consistency were obtained. Item discrimination analysis revealed a majority of the items have moderate to good discriminating power. Confirmatory factor analysis demonstrated distinguishable domain structure as on the original English version. Significant associations were found between lower QOL and more severe motor disability. Consistent with the English version, the highest correlation between the primary caregiver and child forms on QOL was in the domain of functioning. Results of this study indicate that the Chinese CP QOL-Child appears to be valid for use in Mandarin-Chinese speaking children with cerebral palsy.

Teachers' risk perception and needs in addressing infectious disease outbreak.

The outbreak of the Influenza A (H1N1) virus has led to numerous precautionary school closures in several countries. No research is available on the school teachers' perceptions as a health protective resource in controlling communicable disease outbreaks. The purposes of this study were to examine the risk perception, the perceived understanding of preventive measures and contingency plans, and the needs of school teachers before the imminent outbreak of H1N1. This survey was conducted with 1,169 Hong Kong school teachers before school closures due to the H1N1 outbreak. The results showed that the teachers were well aware of H1N1 but were still worried about the spread of H1N1 infection. The teachers' worries depended on their psychological reaction, the adequacy of the control measures, government support in providing infectious disease knowledge, perceived understanding of preventive measures and contingency plans, students and parents' awareness, and the need for support from health professionals.

Heterotopic gastric mucosa (inlet patch) in a patient with laryngopharyngeal reflux (LPR) and laryngeal carcinoma: a case report and review of literature.

The inlet patch is an area of heterotopic gastric mucosa most commonly located in the postcricoid portion of the esophagus at, or just below, the level of the upper esophageal sphincter. Esophageal and supraesophageal symptoms are commonly associated with inlet patch, while esophageal adenocarcinoma rarely complicates it. Laryngeal adenocarcinoma associated with inlet patch is not described in the literature. Herein, we present the first reported case of inlet patch associated with laryngeal carcinoma. A 33-year-old female with long-standing asthma and presumed gastroesophageal reflux developed laryngeal cancer at age 22 years that was treated with concomitant radiation and induction chemotherapy. Subsequently, she had refractory heartburn, dysphagia, and cough. These symptoms continued despite two Nissen fundoplications, glottic web division, and optimal medical management. Upper endoscopy at our institution revealed an upper esophageal stricture and a 1 cm inlet patch. Biopsies showed columnar mucosa (predominantly gastric cardiac/fundic type) consistent with inlet patch, with focal intestinal metaplasia. Subsequent endoscopic mucosal resection of the inlet patch resulted in an amelioration of throat and chest pain, cough, and hoarseness. Dysphagia and regurgitation were improved by serial dilatations of the upper esophageal stricture. This case reveals a number of clinical findings associated with inlet patch--chest pain, dysphagia, cough, and hoarseness--as well as a clinical finding that has not been previously associated with inlet patch: laryngeal cancer. Symptoms refractory to optimal medical management and/or surgical intervention should make the clinician and endoscopist more cognizant of the inlet patch.

Diagnostic yield of capsule endoscopy in ulcerative colitis and inflammatory bowel disease of unclassified type (IBDU).

BACKGROUND AND STUDY AIMS: Capsule endoscopy is increasingly reported as an important diagnostic procedure in patients with known or suspected Crohn's disease, but its clinical utility in patients with ulcerative colitis or unclassified type inflammatory bowel disease (IBDU) is unclear. The aim of our study was to determine the diagnostic yield of capsule endoscopy for small-bowel disease in patients with ulcerative colitis and IBDU. PATIENTS AND METHODS: All data from patients with a history of ulcerative colitis or IBDU who underwent capsule endoscopy between October 2001 and August 2005 were analyzed for procedure indications and findings. Images were reviewed by an experienced capsule endoscopist. The finding of multiple ulcerations (three or more) on capsule endoscopy was classified as diagnostic of small-bowel Crohn's disease. RESULTS: 120 patients had undergone 122 capsule endoscopy procedures. Overall, 19 of 120 patients (15.8 %) had capsule endoscopy findings consistent with the diagnosis of Crohn's disease. The proportion of patients with small-bowel disease was significantly higher among patients with a history of colectomy (7 of 21 patients, 33 %) compared with those without colectomy (12/99, 12 %) ( P = 0.04). Among patients with positive findings on capsule endoscopy, 18 had also previously undergone a small-bowel follow-through study and only one showed findings consistent with Crohn's disease. CONCLUSIONS: Many patients with a diagnosis of ulcerative colitis and atypical features or IBDU may have small-bowel findings on capsule endoscopy that are consistent with Crohn's disease. Capsule endoscopy should be considered in ulcerative colitis patients with atypical clinical features particularly after colectomy.

Helmets for preventing injury in motorcycle riders.

BACKGROUND: Motorcycle crash victims form a high proportion of those killed or injured in road traffic crashes. Injuries to the head, following motorcycle crashes, are a common cause of severe morbidity and mortality. It seems intuitive that helmets should protect against head injuries but it has been argued that motorcycle helmet use decreases rider vision and increases neck injuries. This review will collate the current available evidence on helmets and their impact on mortality, and head, face and neck injuries following motorcycle crashes. OBJECTIVES: To assess the effects of wearing a motorcycle helmet in reducing mortality and head and neck injury following motorcycle crashes. SEARCH STRATEGY: We searched the Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (The Cochrane Library issue 2, 2007), MEDLINE (up to April 2007), EMBASE (up to April week 16, 2007), CINAHL (January 1982 to February 2003), TRANSPORT (up to issue 12, 2006) (TRANSPORT combines the following databases: Transportation Research Information Services (TRIS) International Transport Research Documentation (ITRD) formerly International Road Research Documentation (IRRD), ATRI (Australian Transport Index) (1976 to Feb 2003), Science Citation Index were searched for relevant articles. Websites of traffic and road safety research bodies including government agencies were also searched. Reference lists from topic reviews, identified studies and bibliographies were examined for relevant articles. SELECTION CRITERIA: We considered studies that investigated a population of motorcycle riders who had crashed, examining helmet use as an intervention and with outcomes that included one or more of the following: death, head, neck or facial injury. We included any studies that compared an intervention and control group. Therefore the following study designs were included: randomised controlled trials, non-randomised controlled trials, cohort, case-control and cross-sectional studies. Ecological and case series studies were excluded. DATA COLLECTION AND ANALYSIS: Two authors independently screened reference lists for eligible articles. Two authors independently assessed articles for inclusion criteria. Data were abstracted by two independent authors using a standard abstraction form. MAIN RESULTS: Sixty-one observational studies were selected of varying quality. Despite methodological differences there was a remarkable consistency in results, particularly for death and head injury outcomes. Motorcycle helmets were found to reduce the risk of death and head injury in motorcyclists who crashed. From four higher quality studies helmets were estimated to reduce the risk of death by 42% (OR 0.58, 95% CI 0.50 to 0.68) and from six higher quality studies helmets were estimated to reduce the risk of head injury by 69% (OR 0.31, 95% CI 0.25 to 0.38). Insufficient evidence was found to estimate the effect of motorcycle helmets compared with no helmet on facial or neck injuries. However, studies of poorer quality suggest that helmets have no effect on the risk of neck injuries and are protective for facial injury. There was insufficient evidence to demonstrate whether differences in helmet type confer more or less advantage in injury reduction. AUTHORS' CONCLUSIONS: Motorcycle helmets reduce the risk of death and head injury in motorcycle riders who crash. Further well-conducted research is required to determine the effects of helmets and different helmet types on mortality, head, neck and facial injuries. However, the findings suggest that global efforts to reduce road traffic injuries may be facilitated by increasing helmet use by motorcyclists.

The impact of childhood conditions and concurrent morbidities on child health and well-being.

BACKGROUND: Understanding the impact of illnesses and morbidities experienced by children and adolescents is essential to clinical and population health programme decision making and intervention research. This study sought to: (1) examine the population prevalence of physical and mental health conditions for children and quantify their impact on multiple dimensions of children's health and well-being; and (2) examine the cumulative effect of concurrent conditions. METHODS: We conducted a cross-sectional school-based epidemiological study of 5414 children and adolescents aged 5-18 years, and examined parental reports of child health and well-being using the parent-report Child Health Questionnaire (CHQ) PF50 13 scales are scored on a 0-100 pt scale with clinically meaningful differences of five points and the presence of childhood conditions (illnesses and health problems). RESULTS: Asthma, dental, vision and allergies are the most commonly identified health problems for children and adolescents, followed by attention- and behaviour-related problems (asthma 17.9-23.2%, dental 11.9-22.7%, vision 7.2-14.7%, chronic allergies 8.8-13.9%, attention problems 5.1-13.8% and behaviour problems 5.7-12.0%). As the number of concurrent health problems increase, overall health and well-being decreases substantively with mean differences in CHQ scale scores of 14 points (-7.69 to -21.51) for physical health conditions, and 28 points (-5.15 to -33.81) for mental health conditions. CONCLUSIONS: Children's health and well-being decreases linearly with increasing presence and frequency of health problems. Having three or more conditions concurrently significantly burdens children's health and well-being, particularly for family-related CHQ domains, with a greater burden experienced for mental health conditions than physical health conditions.

Parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural Victoria.

BACKGROUND: Little is known about the oral health of children under the age of four years. The determinants of early childhood caries (ECC) in this young age group are also not well understood despite a growing recognition that early interventions may deliver the greatest benefits. The aim of this study was to examine the oral health-related knowledge, attitudes and reported behaviours of parents of children aged 12-24 months living in rural areas of Victoria, Australia. METHODS: A robust theoretical model was utilized to identify oral health-related behaviours and their antecedent and reinforcing conditions within the context of this specific population group. Two hundred and ninety-four parent/child dyads were recruited through their maternal and child health nurses as part of a larger intervention trial. Parents completed a self-report questionnaire. RESULTS: Knowledge regarding risk and protective factors amongst parents was variable and sometimes at odds with contemporary evidence. Knowledge of the role of early infection with S. mutans was very low, with high levels of behaviours that may promote early transmission reported. Tooth cleaning was reported by most parents at least sometimes, however a large proportion lacked confidence and this was significantly related to the frequency of the cleaning. Parents were confused about the fluoride status of their water supplies. Most parents believed fluoride toothpaste reduced the risk of ECC but did not know whether it should be used with toddlers. CONCLUSIONS: The results of this study have implications for efforts to prevent dental decay in this very young age group. Health care professionals other than dentists need support to provide information and promote confidence with regard to optimal fluoride exposure. Attention should also be given to the contribution of early contact with particular bacteria in oral health education and promotion programmes.

Role of catalytic and lysine-binding sites in plasmin-induced neutrophil adherence to endothelium.

Plasmin resulted in increased neutrophil adherence to cultured ovine pulmonary artery endothelial cell monolayers in a concentration-dependent manner (10(-12)-10(-7) M). The adherence response increased fivefold above baseline within 60 min after addition of plasmin (10(-8) M) and the response persisted up to 30 min after removal of plasmin. The neutrophil adherence was mediated by the action of plasmin on neutrophils rather than endothelial cells. The response was the result of an increase in functional activity of CD18 neutrophil cell surface adhesive glycoprotein. Neutrophil adherence was inhibited by pretreatment of neutrophils with MAbs IB4 and 60.3 targeted against the beta chain of the CD18, whereas control isotypic MAb 60.5 against HLA class I antigen had no effect. The plasmin catalytic site was not involved in the response. Lys-plasminogen had reduced adherence-promoting activity relative to plasmin, whereas glu-plasminogen had no effect. Elastase-derived plasminogen fragments corresponding to kringle 1+2+3 and kringle 4 (both of which contained the lysine-binding sites) possessed neutrophil adherence-promoting activities similar to plasmin, whereas miniplasminogen (which contains the catalytic site but no lysine-binding sites) had minimal effect, indicating the involvement of lysine-binding sites in the response. Blocking lysine-binding sites of plasmin and elastase-derived plasminogen fragments with tranexamic acid (IC50 of 5 mM) inhibited neutrophil adherence. A monospecific polyclonal antibody against the lysine-binding sites also reduced the neutrophil adherence-promoting activity of plasmin. The results indicate that plasmin induces neutrophil adherence to the endothelium and that the effect is mediated by lysine-binding sites on plasmin.

Tumor necrosis factor mediates experimental pulmonary edema by ICAM-1 and CD18-dependent mechanisms.

(TNF alpha)-induced sequestration of neutrophils (PMN) in lungs and of the resultant PMN-dependent pulmonary edema. Guinea pig lungs perfused with Ringers-albumin were challenged with TNF alpha (1,000 U/ml) for 90 min, followed by addition of fresh perfusate containing 2 x 10(7) human PMN. TNF alpha challenge caused sequestration of PMN in the pulmonary vascular bed as indicated by a threefold increase in lung tissue myeloperoxidase activity (MPO). The activation of the sequestered PMN with phorbol 12-myristate 13-acetate (PMA; 5 x 10(-9) M) produced threefold increases in pulmonary artery (Ppa) and pulmonary capillary hydrostatic (Pcap) pressures, and twofold increases in lung wet-to-dry weight (W/D) ratio and capillary filtration coefficient (Kf,c) over baseline. TNF alpha prestimulation was required for these responses since activation of PMN with PMA in control lungs produced smaller increases in Ppa and Pcap (P less than 0.01) and did not change the W/D and Kf,c. TNF alpha prestimulation also induced the expression of intercellular adhesion molecule (ICAM-1) on pulmonary vascular endothelial cells. Monoclonal antibodies (mAbs) to the neutrophil CD18 integrin (beta-chain of CD11/CD18 complex) (mAb IB4) and to its endothelial cell ligand ICAM-1 (mAb RR1/1) were used to examine the role of PMN adhesion in the TNF alpha-induced responses. Pretreatment of PMN with mAb IB4 prevented PMN uptake and increases in Ppa, Pcap, Kf,c, and W/D ratio. Addition of mAb RR1/1 to the perfusate reduced PMN uptake by 58%, and prevented the increases in Ppa, Pcap, Kf,c, and W/D ratio, as with mAb IB4. The findings indicate that TNF alpha prestimulation of lungs mediates PMN uptake and that this requires the expression of ICAM-1 and its interaction with CD18 integrin on PMN. The activation of PMN sequestered by ICAM-1-dependent mechanism contributes to the development of pulmonary vascular injury and edema.

In vivo expression of neutrophil inhibitory factor via gene transfer prevents lipopolysaccharide-induced lung neutrophil infiltration and injury by a beta2 integrin-dependent mechanism.

The binding of beta2 (CD18) integrins on PMN cell membrane to intercellular adhesion molecule (ICAM) counter-receptors on the surface of vascular endothelial cells mediates PMN adhesion to endothelial cells. Neutrophil inhibitory factor (NIF), a 41-kD glycoprotein isolated from the canine hookworm (Ancylostoma caninum), is a beta2 integrin antagonist that inhibits PMN adhesion to endothelial cells. We transferred the NIF gene into CD1 mouse lungs by intravenous injection of cationic liposomes to study the effects of in vivo NIF expression on LPS-induced lung PMN sequestration and the development of lung injury. RT-PCR and Northern blot analysis indicated the lung-selective expression of the NIF transgene, and immunocytochemistry showed prominent NIF expression in pulmonary microvessel endothelial cells. NIF staining was also observed in intraluminal leukocytes present in pulmonary microvessels. This may be the result of NIF binding to leukocytes after its secretion from the transduced lung cells, since there was no evidence of NIF gene expression in circulating leukocytes. Pulmonary vascular NIF expression abrogated the lung tissue PMN uptake and airspace migration of PMN and prevented lung vascular injury (as measured by the lung tissue uptake of [125I]labeled albumin) after the intraperitoneal LPS challenge (200 microg/mouse). Expression of a control protein, chloramphenicol acetyltransferase (CAT), by the same strategy, had no effect on these responses. In vitro studies showed that NIF prevented mouse PMN adhesion consistent with the inhibition of lung uptake after LPS challenge in NIF transgene-expressing mice. We conclude that pulmonary vascular expression of NIF, a specific beta2 integrin- binding protein, is a potentially useful gene transfer strategy in modulating the infiltration of PMN across the alveolar-capillary epithelial barrier and in preventing lung vascular endothelial injury.

Activation of cultured vascular endothelial cells by antiphospholipid antibodies.

Circulating antiphospholipid antibodies (aPL) are associated with a syndrome of thrombosis, recurrent fetal loss, and thrombocytopenia. We have demonstrated the activation of cultured human umbilical vein endothelial cells (HUVEC) by IgG from patients with anticardiolipin antibodies (aCL). Incubation of HUVEC for 4 h with purified IgG (100 micrograms/ml) from patients with high-titer aCL induced a 2.3-fold increase in monocyte adhesion over that seen in HUVEC incubated with IgG's from normal subjects. The effect of aCL was not attributable to LPS contamination, Fc receptors, or immune complexes. Monocyte adhesion was not induced when the aCL were added in serum-free media but was restored by the addition of purified beta 2GP1, previously described as a necessary cofactor for aCL reactivity. Purified rabbit polyclonal IgG raised against beta 2GP1 also induced monocyte adhesion when incubated with HUVEC. Preadsorption of patient serum with cardiolipin reduced monocyte adhesion by 60%. Immunofluorescent microscopy demonstrated that endothelial cells incubated with patient IgG expressed cell adhesion molecules, including E-selectin, vascular cell adhesion molecule-1, and intracellular adhesion molecule-1. These data support the hypothesis that aPL activate vascular endothelial cells, thereby leading to a pro-thrombotic state.

Abdominal compartment syndrome secondary to retroperitoneal hematoma as a complication of ERCP after liver transplantation.

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently employed in the management of postoperative biliary complications in the liver transplant patient. Bleeding after ERCP most commonly presents as gastrointestinal bleeding and often can be managed with repeat endoscopy. ERCP can also be complicated by retroperitoneal hematoma, which in rare cases can lead to hemodynamic compromise due to relentless hemorrhage or from secondary abdominal compartment syndrome. We describe the first reported case of post-ERCP retroperitoneal hematoma in a liver transplant recipient that led to abdominal compartment syndrome and shock liver. We will present the case, discuss management, and review the complications of ERCP in the liver transplant recipient. Close post-procedure monitoring, rapid detection, and low threshold for decompressive laparotomy are keys to the successful management of the liver transplant recipient experiencing expanding retroperitoneal hematoma after ERCP.

Construct validity of the Chinese version of the disabilities of the arm, shoulder and hand questionnaire (DASH-HKPWH).

The study evaluated the construct validity of the Chinese Hong Kong version of the disabilities of the arm, shoulder and hand questionnaire (DASH-HKPWH). Three hundred and thirty four patients with a broad range of upper extremity disorders were recruited into the study. Each completed DASH-HKPWH and SF-36 forms and their pain intensity (numeric pain rating scale) and grip strength were also measured. The mean DASH-HKPWH score was 40 (SD=20). Principal component factor analysis identified a single factor, which accounted for 47% of the total variance. Pearson correlation was applied to assess convergent and divergent validity of the DASH-HKPWH by comparison with the above-mentioned subjective and objective measurements. Our findings were comparable to the DASH of other languages.

Estrogen improves motor disability in parkinsonian postmenopausal women with motor fluctuations.

OBJECTIVE: To test the efficacy, tolerance, and safety of low-dose oral estrogen in postmenopausal women with PD associated with motor fluctuations. BACKGROUND: Motor fluctuations in PD may be predictable or unpredictable, and eventually affect most patients after long-term levodopa therapy. Although estrogen can modulate nigrostriatal dopamine levels, its effects on PD are unclear. METHODS: Patients were randomized to receive conjugated estrogen (oral Premarin 0.625 mg daily; n = 20) or placebo (n = 20) in a double-blind, parallel-group, prospective study over 8 weeks. Existing antiparkinsonian drug regimes were kept unchanged. Changes in "on" and "off" periods using patient diaries, Unified Parkinson's Disease Rating Scale (UPDRS) score, timed tapping score, and Hamilton Depression Scale score were determined by one rater. Subgroup analyses were also performed on patients with only predictable motor fluctuations. RESULTS: Both treatment groups were similar in age, duration of disease and menopause, antiparkinsonian medication, and compliance with test medication and diary assessments. "On" and "off" times, and motor score (UPDRS subscale III) improved with estrogen, using the Mann-Whitney U test (p < 0.05 after Bonferroni adjustment). Mean "on" time improved by 7% (9 hours/week of awake time) in estrogen-treated patients versus a deterioration of 0.5% (1.4 hours) in placebo-treated patients (95% confidence interval, [CI] of mean difference, 5.73 to 14.9). Mean "off" time improved by 4% (4.4 hours/week of awake time) in estrogen-treated patients versus no change in placebo-treated patients (95% CI, 1.54 to 7.16). Mean subscale III score improved by 3.5 points in estrogen-treated patients versus 0.4 in placebo-treated patients (95% CI, 1.02 to 5.18). No other significant changes were observed (p > 0.05). Subgroup analyses in patients with only predictable motor fluctuations showed similar results, except improvement in mean subscale III score was marginally not significant (p = 0.07; 95% CI, 1.06 to 6.24). Five patients on estrogen had facial flushing, three had lower abdominal discomfort, and two had mild withdrawal vaginal bleeding. The adverse events were mild and resolved without sequelae. CONCLUSION: Low-dose estrogen is a safe and effective adjunct therapy to existing antiparkinsonian treatment in reducing motor disability in postmenopausal women with PD associated with motor fluctuations.

A case-controlled MRI/MRA study of neurovascular contact in hemifacial spasm.

BACKGROUND: Neurovascular contact (NVC) with the root exit zone (REZ) of the ipsilateral facial nerve is associated with hemifacial spasm (HFS), but unresolved issues remain. OBJECTIVES: To 1) determine the frequency of symptomatic and nonsymptomatic NVC, 2) determine the features of NVC associated with HFS, and 3) correlate severity of HFS to these features. METHODS: Two independent, blinded, prospective assessments of high-resolution MR and MR angiography (MRA) images were performed on Chinese cases (HFS: n = 44; age-matched control subjects: n = 20). RESULTS: Over 88% of 44 symptomatic sides in patients with HFS had NVC of the ipsilateral facial nerve. At least 80% of symptomatic sides involved NVC at the anterior aspect of the REZ [REZ(ant.)]. Although NVC was observed in approximately half of nonsymptomatic sides, at least 70% of them were not at REZ(ant.). NVC at the cisternal and intracanalicular portions of the facial nerve were not associated with HFS. Half of our patients with HFS had bilateral NVC, but none had bilateral symptoms. Most of our MR/MRA images showed that the size and position of the arterial branches of the vertebrobasilar system were markedly asymmetric. Of patients with bilateral NVC, over 83% had asymmetric NVC sites. The anterior inferior cerebellar artery was the most common vessel involved in NVC, but was not significantly associated with HFS. Most of the NVC involved one vessel at one contact point with no indentation. The development of HFS was significantly associated with nerve indentation in NVC. The development and severity of HFS were not associated with multiple contact points in NVC. No significant interobserver variability existed between the blinded assessments. CONCLUSIONS: MRI/MR angiography are accurate, fast, and safe in characterizing neurovascular contact (NVC) at the brainstem. The site of NVC and ipsilateral facial nerve indentation in NVC are significant determinants for the development of hemifacial spasm (HFS). The lack of bilateral NVC at the anterior aspect of the root exit zone of the facial nerve could explain in part the lack of bilateral symptoms. The development and severity of HFS are not associated with a specific blood vessel or multiple contact points in NVC.