Concussion history associated with increased postural control deficits after subsequent injury.

OBJECTIVE: Postural control deficits have been extensively reported following sport-related concussions. Concussed athletes demonstrate these deficits as early as 24 h post-concussion and may persist for up to six months. Many of these prior studies have included mixed samples with prior injury history that may affect the postural control data. The purpose of this investigation was to evaluate the effect of concussion history on postural control 24-48 h following sport-related concussion in Division I athletes. APPROACH: Twenty-eight Division I athletes (seven athlete controls (CON), seven no history (SRC0), seven with a previous concussion (SRC1), and seven with 2-3 concussions (SRC3) participated in this study. All participants were assessed within 24-48 h post-subsequent SRC and performed three trials of quiet stance in the eyes closed (EC) conditions for 30 s each on a force platform (1000 Hz). The data were analyzed with root mean square (RMS) and mean excursion velocity (MEV) in the anteroposterior (AP) and mediolateral (ML) directions. Two 3 × 2 MANOVAs were run by direction for group comparisons. MAIN RESULTS: SRC2 had significantly greater RMS than CON, SRC0, and SRC1 in the AP direction and ML direction. SRC2 exhibited significantly greater AP and ML MEV than CON, SRC0, and SRC1. SIGNIFICANCE: These results demonstrate that having 2-3 prior concussions negatively affects the postural system after a subsequent head injury. Sports medicine staff should approach the recovery process with caution with those that have a prior history of concussion, due to the negative effects that history of concussion has on postural control strategies.

Diagnostic features of tuberculous peritonitis in the absence and presence of chronic liver disease: a case control study.

PURPOSE: To determine diagnostic features of tuberculous peritonitis (TBP) in the absence and presence of chronic liver disease. PATIENTS AND METHODS: Thirty-four patients with TBP (13 without [Group I] and 21 with chronic liver disease [Group II] and 26 controls with cirrhosis and uninfected ascites (Group III) were studied. RESULTS: The clinical features in Groups I and II were similar and all patients had elevated ascitic fluid total mononuclear cell count. In Groups I, II, and III, respectively, ascitic fluid protein was > 25 g/L in 100% (13/13), 70% (14/20), and 0% (0/26); serum-ascites albumin gradient (SAAG) was > 11 g/L in 0% (0/13), 52% (11/21), and 96% (25/26), (0% [0/13], 71% [15/21], and 96% [25/26] after correction for serum globulin); and ascitic fluid lactate dehydrogenase (LDH) level was > 90 U/L in 100% (12/12), 84% (16/19), and 0% (0/20), respectively. In Groups I and II combined, ascitic fluid acid-fast stain was negative in all but Mycobacterium tuberculosis culture was positive in 45% (10/22); peritoneal nodules occurred in 94% (31/33), granulomas in 93% (28/30), and positive peritoneal M tuberculosis culture in 63% (10/16). CONCLUSIONS: In patients with suspected TBP, ascitic fluid protein of > 25 g/L, SAAG of < 11 g/L and LDH of > 90 U/L have high sensitivity for the disease. With coexistent chronic liver disease, a lower protein level and higher SAAG are usually not helpful but LDH > 90 U/L is a useful parameter for screening. Diagnosis is best confirmed by laparoscopy with peritoneal biopsy and M tuberculosis culture.

Hyperlipidemia after liver transplantation: natural history and treatment with the hydroxy-methylglutaryl-coenzyme A reductase inhibitor pravastatin.

This study was designed to determine the frequency of hyperlipidemia after orthotopic liver transplantation and whether treatment with a hydroxy-methylglutaryl coenzyme A reductase inhibitor was safe and efficacious. Cholesterol levels were assessed in 45 consecutive adult liver transplants (mean +/- SE). Four of 22 patients on cyclosporine (CsA) (18%) and three of 23 patients on FK506 (13%) had levels >225 mg/dl at 12 months (cholesterol levels for patients on CsA [total n=22]: pre-Tx = 140+/-11, 1 month = 183+/-36,3 months = 221+/-12, 6 months = 211+/-11, 12 months = 202+/-14 [P<0.01 vs. pre-Tx]; FK506 [total n=23]: Pre-Tx = 151+/-13, 1 month = 187+/-22, 3 months = 188+/-10, 6 months = 184+/-13, 12 months = 164+/-9 [P=0.02 vs. CsA]). A separate cohort of patients with stable graft function, cholesterol >225 mg/dl, and two additional risk factors for coronary artery disease were started on pravastatin. Ninety-eight patients were enrolled. Sixteen patients (16%) discontinued the drug because of subjective complaints. No episodes of rhabdomyolysis or hepatotoxicity occurred (cholesterol levels for patients on CsA [total n=65]: pretreatment = 251+/-7, 6 months = 220+/-7 [P=0.01 vs. pretreatment], 12 months = 224+/-8 [P=0.01 vs. pretreatment]; FK506 [total n=17]: pretreatment = 251+/-17, 6 months = 219+/-17, 12 months = 208+/-17 [P=0.08 vs. pretreatment]). Natural killer cells isolated from normal volunteers (n=14) exhibited 27+/-9% specific lysis. Patients on FK506 or cyclosporine-based immunosuppression alone (n=11) exhibited 20+/-4% specific lysis. Standard immunosuppression plus pravastatin (n=10) decreased lysis to 0.2+/-10% (P<0.02 vs. controls and standard immunosuppression). We conclude: (1) posttransplant hyperlipidemia occurs less frequently in liver transplant patients than in renal or cardiac transplants; (2) pravastatin is safe and efficacious for cholesterol reduction in liver transplant patients; and (3) pravastatin coadministered with standard immunosuppression reduces natural killer cell-specific lysis in these recipients.

Pseudointimal biliary epithelial proliferation and Zahn's infarct associated with a 6 1/2-month-old transjugular intrahepatic portosystemic shunt.

The transjugular intrahepatic portosystemic shunt has recently become widely used for portal decompression. Shunt stenosis resulting from pseudointimal hyperplasia and hepatic encephalopathy are emerging as important midterm complications of the procedure. Bile extravasation caused by bile duct transection by the stent wires has been suggested as a cause of the pseudo-intimal hyperplasia. The present case report describes a 6 1/2-month-old transjugular intrahepatic portosystemic shunt in which apparent biliary epithelial proliferation had formed large cyst-like spaces within the pseudo-intima at the site of shunt stenosis. We hypothesize that secretory products from these biliary epithelial cells may have contributed to shunt stenosis by creating expansile cysts or by stimulating pseudointimal hyperplasia. In addition, we found a large, recent Zahn's infarct adjacent to the stent. Pseudointimal hyperplasia had extended from the stent wires into the orifices of contiguous small portal and hepatic vein branches. The resulting stenosis of these small veins may have contributed to the Zahn's infarct.

Padres Trabajando por la Paz: a randomized trial of a parent education intervention to prevent violence among middle school children.

This paper reports the results of a randomized trial to test the effectiveness of a theoretically derived intervention designed to increase parental monitoring among Hispanic parents of middle school students. Role model story newsletters developed through the process of Intervention Mapping were mailed to half of a subsample of parents whose children participated in Students for Peace, a comprehensive violence prevention program. The results indicated that parents in the experimental condition (N = 38) who had lower social norms for monitoring at baseline reported higher norms after the intervention than the parents in the control condition (N = 39) (P = 0.009). Children of parents in the experimental group reported slightly higher levels of monitoring at follow-up across baseline values, whereas control children who reported moderate to high levels of monitoring at pre-test reported lower levels at follow-up (P = 0.04). These newsletters are a population-based strategy for intervention with parents that show some promise for comprehensive school-based interventions for youth.

Failure of providers to vaccinate HIV-infected men against hepatitis B: a missed opportunity.

OBJECTIVE: To carry out an audit of hepatitis B immunization practices in an outpatient HIV clinic. METHODS: We reviewed the medical records of all new HIV-infected patients seen between October 1, 1990 and December 31, 1991. RESULTS: The 125 patients were men with a mean age and CD4 count of 43 yr and 240 cells/mm3, respectively. Fourteen percent (14%) of men who showed a clear need for vaccine, having no HBV markers, were not vaccinated by the clinic staff. Further, 16% whose susceptibility to HBV infection was unclear, with anti-HBc as a sole HBV marker, were not evaluated with a booster dose of hepatitis B vaccine in an attempt to elicit an anamnestic response. CONCLUSIONS: In failing to vaccinate or evaluate the 30% of patients without HBsAg or anti-HBs, our providers are missing an important opportunity in preventive medicine. We urge others to examine their own hepatitis B screening and vaccination practices.

Depression and substance use in minority middle-school students.

OBJECTIVES: This study investigated the association between depression and substance use in a sample of middle-school students. METHODS: The 5721 students (59%-63% Hispanic) completed self-report items on depressive symptoms, recent smoking and binge drinking, and lifetime use of marijuana, cocaine, and inhalants. RESULTS: Symptoms of depression were strongly and positively related to substance use. For every type of use, a stepwise increase was seen between the percentage of students with low symptom frequency and the percentage of students with more symptoms. A sizable number of users reported symptoms indicating major depression. Depression scores showed few clinically meaningful differences among demographic subgroups. Substance use scores, in contrast, showed meaningful intergroup differences for racial/ethnic group and other demographic variables. CONCLUSIONS: Depressive symptoms and substance use were associated in a sample of middle-school students who were largely non-White and predominantly Hispanic. Greater understanding of the nature of this association is needed; this understanding should be used to design prevention programs, and prevention programs should be introduced at least in the middle-school years.

Successful treatment of mycotic hepatic artery pseudoaneurysms with arterial reconstruction and liposomal amphotericin B.

A 55-year-old woman developed end-stage liver disease and the hepatorenal syndrome secondary to cryptogenic cirrhosis. Orthotopic liver transplantation was complicated by bile peritonitis, requiring reoperation and eventual placement of an internal biliary stent. On postoperative day 26, hemobilia was caused by localized rupture of mycotic (Aspergillus fumigatus) hepatic artery pseudoaneurysms with fistulization into the biliary tree. After arterial reconstruction with a reversed autologous saphenous vein graft, the patient was treated successfully with liposomal amphotericin B.

Physical activity among African American and Latino middle school girls: consistent beliefs, expectations, and experiences across two sites.

Physical inactivity is a major public health concern. Low levels of physical activity are reported in many subgroups of women including adolescent girls. More data are needed to better understand factors related to physical activity participation in adolescent girls. Therefore, we explored adolescent girls' reasons for participating and not participating in physical activity. Two independent samples were taken in California and Texas; the total sample included thirty-four African American and Latino girls. Six focus groups were conducted by trained facilitators. Based on independent qualitative analyses, six replicated themes emerged from the focus groups. Fun, social support, and concern with body image facilitated participation in activity. In contrast, negative experiences in physical education classes, concerns about appearance after activity, and lack of opportunity impeded participation in activity. Overall, the girls showed an interest in physical activity and identified activity motivators and barriers. We discuss the implications of our findings for future research.

Reduction of hepatic ischemia/reperfusion injury by a soluble P-selectin glycoprotein ligand-1.

OBJECTIVE: The authors' goal was to determine the effects of specific binding and blockade of P- and E-selectins by a soluble P-selectin glycoprotein ligand-1 (PSGL-1) in rat models of hepatic in vivo warm ischemia and ex vivo cold ischemia. The authors also sought to determine the effect of selectin blockade on isograft survival in a syngeneic rat orthotopic liver transplant model. SUMMARY BACKGROUND DATA: Ischemia/reperfusion (I/R) injury is a major factor in poor graft function after liver transplantation, which may profoundly influence early graft function and late changes. It is hypothesized that I/R injury leads to the upregulation of P-selectin, which is then rapidly translocated to endothelial cell surfaces within 5 minutes of reperfusion of the liver, initiating steps leading to tethering of polymorphonuclear neutrophil leukocytes to the vascular intima. Local production by leukocytes of interleukin-1, tumor necrosis factor-alpha, or both induces P-selectin expression on the endothelium and continues the cascade of events, which increases cell adherence and infiltration of the organ. METHODS: To examine directly the effects of selectins in a warm hepatic I/R injury model, 100 microg of PSGL-1 or saline was given through the portal vein at the time of total hepatic inflow occlusion. The effects of PSGL-1 in cold ischemia were assessed using an isolated perfused rat liver after 6 hours of 4 degrees C storage in University of Wisconsin (UW) solution, with or without the instillation of PSGL-1 before the storage. To evaluate the effect of selectin blockade on liver transplant survival, syngeneic orthotopic liver transplants were performed between inbred male Sprague-Dawley rats after 24 hours of cold ischemic storage in UW solution. A separate group of animals received two doses of 100 microg of PSGL-1 through the portal vein before storage and before reperfusion of the transplanted liver. Recipient survival was assessed at 7 days, and the Kaplan-Meier product limit estimate method was used for univariate calculations of time-dependent recipient survival events. RESULTS: In an in vivo warm rat liver ischemia model, perfusion with PSGL-1 afforded considerable protection from I/R injury, as demonstrated by decreased transaminase release, reduced histologic hepatocyte damage, and suppressed neutrophil infiltration, versus controls (p < 0.05). When cold stored livers were reperfused, PSGL-1 reduced the degree of hepatocyte transaminase release, reduced neutrophil infiltration, and decreased histologic hepatocyte damage (p < 0.05 vs. UW-only controls). On reperfusion, livers treated with PSGL-1 demonstrated increased portal vein blood flow and bile production (p < 0.05 vs. UW-only controls). In addition, 90% of the rats receiving liver isografts stored in UW solution supplemented with PSGL-1 survived 7 days versus 50% of those whose transplanted syngeneic livers had been stored in UW alone (p < 0.05). CONCLUSIONS: Selectins play an important role in I/R injury of the liver. Early modulation of the interaction between P-selectin and its ligand decreases hepatocyte injury, neutrophil adhesion, and subsequent migration in both warm and cold rat liver ischemia models. In addition, the use of PSGL-1 before ischemic storage and before transplantation prevents hepatic injury, as documented by a significant increase in liver isograft survival. These findings have important clinical ramifications: early inhibition of alloantigen-independent mechanisms during the I/R damage may influence both short- and long-term survival of liver allografts.

Prophylaxis against hepatitis B recurrence following liver transplantation using combination lamivudine and hepatitis B immune globulin.

Patients undergoing liver transplantation for hepatitis B-related liver disease are prone to recurrence. The mainstay of prophylaxis has been passive immunotherapy with hepatitis B immune globulin (HBIG). Antiviral therapy with lamivudine has proven effective in lowering hepatitis B virus (HBV) DNA and improving histology in patients with hepatitis B infection; its role in prophylaxis against hepatitis B recurrence following liver transplantation is under investigation. Viral breakthrough and resistance, however, are a significant problem with monotherapy with either HBIG or lamivudine. The efficacy of combination lamivudine/HBIG prophylaxis has not been reported. Fourteen patients underwent transplantation for decompensated liver disease owing to hepatitis B. Lamivudine (150 mg p.o./d) was begun before transplantation in 10 patients, including 4 who were HBV DNA-positive. In addition, 1 patient was HBV DNA-positive when transplanted. HBIG was given perioperatively and continued thereafter; treatment with lamivudine was maintained or initiated at the time of transplantation and continued indefinitely. The median follow-up was 387 days. Actuarial 1-year patient and graft survival was 93% (1 patient died of unrelated causes). At a median interval of 28 days following lamivudine treatment, all 5 HBV DNA-positive patients cleared HBV DNA from the serum; 1 went on to clear hepatitis B surface antigen (HBsAg), before transplantation, at day 148 of lamivudine treatment. By the highly sensitive polymerase chain reaction (PCR), at a median of 346 days (range, 130-525 days) following transplantation, all 13 surviving patients had no detectable serum HBV DNA. Lamivudine suppresses HBV replication in patients awaiting liver transplantation. At a median follow-up of 1.1 years, combination prophylaxis with lamivudine and HBIG prevented hepatitis B recurrence following liver transplantation.