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.

A validation study of the Chinese wearing off questionnaire 9-symptom for Parkinson's disease

OBJECTIVE

Development of wearing off (WO) often goes unnoticed for both patients with Parkinson's disease (PD) and physicians due to the complexity of this phenomenon. A brief 9-symptom WO questionnaire (WOQ-9) was recently found to be highly sensitive in its detection. We aimed to validate a Chinese version WOQ-9 (CWOQ-9) among Chinese patients with PD.

METHODS

We recruited 101 literate Chinese PD patients among 4 different neurology or movement disorders clinics in Hong Kong to participate in this study by completing the CWOQ-9. Clinical judgment by the specialists was considered the gold standard for diagnosing WO.

RESULTS

The mean age (±SD) of the patients was 61 (±9) years and 35 (34.7%) of them were female. The disease duration was 7.4 (±5.4) years and 69 (68.3%) of them were diagnosed clinically to have WO by the specialists. The positive and negative predictive values, sensitivity and specificity of CWOQ-9 were 86%, 71%, 87%, and 69% respectively. The area under curve (AUC) was 0.78 (p<0.001).

CONCLUSION

This simple patient questionnaire is a valid tool for the detection of WO among Chinese PD patients.

Idiopathic inflammatory demyelinating disorders after acute transverse myelitis

Acute transverse myelitis (ATM) is commonly para-infectious. Recurrent ATM occurs in connective tissue diseases (CTD), infective myelitis and idiopathic inflammatory demyelinating disorders (IIDD) including multiple sclerosis (MS) and neuromyelitis optica (NMO). Previous studies might include NMO and idiopathic recurrent transverse myelitis (IRTM) as MS. The aim was to study the outcome of patients after a first attack of idiopathic ATM. Idiopathic ATM patients over a 6-year period were retrospectively studied. Known causes of myelopathy were excluded. Among 32 patients studied, 20 (63%) had single ATM attack upon follow up for 39-93 months, three developed recurrent ATM related to CTD (two systemic lupus erythematosus and one anti-Ro antibody positive) and nine (28.1%) developed recurrent neuroinflammation compatible with IIDD. Among IIDD patients, three had NMO, two restricted variant of NMO, three IRTM and one classical MS. NMO, its variant and IRTM had mean spinal MRI abnormality of 3.7, 2.1 and 3.9 vertebral segments respectively while non-recurrent ATM had 1.6 vertebral segments. Four (80%) of the five patients with NMO or its variant had poor neurological prognosis versus only one (5%) of non-recurrent ATM patients. IRTM patients had advanced mean onset age, 62 years vs. 43 years for non-recurrent ATM patients. In IIDD patients presenting with ATM as first attack of neuroinflammation, NMO and its variant (56%) were most frequent, then IRTM (33%), with classical MS (11%) the rarest. As long-term treatments for NMO are different from MS, early recognition of NMO and its variant is important for prevention of serious neurological deficits.

An epidemiological study of motor neuron disease in Hong Kong

Worldwide, the incidence of motor neuron disease (MND) has been increasing steadily over recent decades. We reported a follow-up epidemiology study of MND in this locality. We identified the subjects from the computer database of the government hospital system between 1 January 1997 and 31 January 2002 by searching the ICD code starting from 335.xx. Every retrieved case or their records were reviewed and validated by neurologist(s) of the responsible regional hospitals which the patients attended. One hundred and twenty cases from seven regional hospitals (serving 48.05% of the HKSAR population) were identified, validated and confirmed to be MND or related diseases. Ninety-eight new cases were diagnosed during the study period. Average age of onset was 58.76 years; SD 14.12 (28-89) years. Male to female ratio was 1.72:1. Peak age of onset was 60-64 years without sex difference. The adjusted incidence rate was 0.60/100,000/year. The adjusted point prevalence at the prevalence date (31 January 2001) was 3.04/100,000. Despite the incidence and prevalence of MND among Hong Kong Chinese, it remained low compared to worldwide figures, and our data suggested a significant rise of MND or related disease in the last decade. A territory-wide prospective epidemiological study is indicated.

Bath-related headache

Bath-related headache (BRH) is a rare primary headache syndrome. We present our experience over seven years and review all reported cases of BRH. Thirteen patients, including six from our group, are described. BRH occurred exclusively in middle-aged or elderly Oriental women (mean age 51 years, range 32-67. Hong Kong 6 cases, Taiwan 4 cases, Japan 3 cases). The typical presentation was a uniphasic cluster of severe headache recurrently triggered by bathing or other activities involving contact with water. Each attack lasted 30 min to 30 h. Onset was hyperacute, consistent with that of thunderclap headache. Reversible multisegmental cerebral vasoconstriction was found in two patients. No underlying secondary causes were identified. Response to acute treatment was generally unsatisfactory, but headache could be prevented by avoiding the specific trigger(s). BRH runs a self-limiting course; all patients remitted within three months after onset. Nimodipine may shorten the duration of illness.

Clinical relevance of hydrocephalus as a presenting feature of tuberculous meningitis

BACKGROUND

Hydrocephalus is a common complication of tuberculous meningitis (TBM).

AIM

To study the incidence, associated clinical features, and impact on outcome of hydrocephalus at presentation in TBM.

DESIGN

Observational study.

SETTING

Regional hospital serving 500,000 people.

METHODS

Adult patients with TBM were studied over 57 months. Those with hydrocephalus on initial CT scan were assessed by neurosurgeons. Clinical, neuroradiological, and biochemical features of patients with hydrocephalus upon presentation were compared to those without initial hydrocephalus.

RESULTS

Of 31 TBM patients during the study period, nine (29.0%) had hydrocephalus at presentation, and eight of them (25.8% of all) underwent urgent neurosurgical intervention. Of the 22 patients without initial hydrocephalus, hydrocephalus developed after commencement of chemotherapy in one patient only. Hydrocephalus at presentation was associated with a longer duration of presenting symptoms (p = 0.01), ataxia (p = 0.001), later stages of TBM (p = 0.045), a longer delay before commencement of anti-tuberculous chemotherapy (p = 0.001), stroke (p = 0.012), and a poor outcome at 1 year (p = 0.001).

DISCUSSION

Hydrocephalus upon presentation is common in our TBM patients. This may be a poor prognostic marker associated with severe TBM and a higher risk of stroke.

Tuberculous meningitis with tuberculomata presenting as postpartum pyrexia of unknown origin

A35-year-old Chinese woman had primary infertility as a result of bilateral fallopian tube blockage. She had had uterine fibroids resected 3 years previously. Her precious pregnancy via in-vitro fertilization was complicated by premature rupture of amniotic membrane at 18 weeks' gestation. Two doses of betamethasone 12 mg were given at 29 weeks' gestation, and fetal bradycardia was noted on the next day. A baby girl was delivered by emergency caesarean section. The patient had a high swinging fever following the delivery. Extensive investigations for postpartum pyrexia were normal or negative. She was given courses of broad-spectrum antibiotics for 4 weeks before she developed mental dullness and right partial ptosis. On the next day, she became disorientated with left hemiplegia. Examination also revealed left-sided neglect, dysphasia, conjugate gaze deviation to the right, and left homonymous hemianopia. Computed tomography (CT) of the brain revealed a left temporal hypodense area (Figure 1a). Lumbar puncture revealed the following CSF findings: opening pressure of 34 cmH2O, protein level of 3.8 g/litre, glucose level of 2.1 mM (serum 6.4 mM), cell count of 30 × 106/litre (56% lymphocytes, 40% neutrophils, 4% monocytes), and red cell count of 11 × 106/litre. Other CSF tests were negative.

Prospective study of selective peripheral denervation for botulinum-toxin resistant patients with cervical dystonia

We have carried out a prospective study of selective peripheral denervation (SPD) in cervical dystonia (CD) patients with primary or secondary botulinum toxin (BT) treatment failure using independent standardized assessment. Patients referred for surgery had a standardized clinical examination, neck muscle EMG, videofluoroscopic swallow and CT of the cervical spine, and were selected for surgery on the basis of the results of these investigations. CD severity, disability and pain were assessed preoperatively and at 3, 6, 9, 12 and 18 months postoperatively using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Severity of head tremor and dysphagia were scored using established rating scales. Additionally, psychosocial function was assessed in a representative subsample of patients (n = 12) using several established questionnaires. Of the 62 patients who were assessed, 22 (35.5%) were not offered surgery, most commonly because of widespread dystonia. Of the remaining 40 patients, 37 have so far had surgery, 31 of whom have been followed up for at least 1 year, and 15 for 18 months after surgery (mean follow-up duration 16.7 months). Using the TWSTRS global outcome score, 68% of patients derived functionally relevant improvement at 12 months after surgery. In the entire operated group, total TWSTRS scores were reduced by 30% at 6 and 12 months after surgery (P < 0.0001). The subscores for severity, disability and pain were reduced by 20, 30 and 40%, respectively, at 6 months (P < or = 0.01) and 20, 40 and 30%, respectively, at 12 months (P < 0.01). Pain increased over time, which appeared to result from muscle reinnervation. TWSTRS scores were not significantly improved in the six patients with primary BT treatment failure. Head tremor did not change. There was a significant improvement of body concept, perceived disfigurement, stigma, and quality of life in the 12 patients whose psychosocial function was assessed. Preoperative disability and restriction of head movement were negatively correlated and the initial response to BT treatment positively correlated with global outcome score. Spread or deterioration of dystonia elsewhere in the body occurred in three patients, with unpleasant sensory symptoms in denervated posterior cervical segments occurring in 14. Ten patients developed mild to moderate dysphagia, and two developed severe dysphagia. We conclude that SPD is an effective treatment for patients with secondary, but probably not for those with primary, BT treatment failure. Reinnervation is not infrequent and can compromise outcome. Postoperative morbidity is low, but there is a risk of dysphagia.

Clinical characteristics of adult epilepsy patients in the 1997 Hong Kong epilepsy registry

OBJECTIVE

To study the clinical characteristics of 2952 patients with epilepsy who had received drug treatment from the neurology outpatient clinics of eight major hospitals in Hong Kong.

METHODS

Retrospective review of outpatient records.

RESULTS

1601 (54.3%) males and 1351 (45.7%) females with a median age of 35.8 years (range, 10-94.8) were studied. Seizure types included generalized tonic-clonic in 80.7% of patients, complex partial in 28.3%, simple partial in 14.4%, atypical absence in 2.6% and myoclonic in 1.4%, and 30.4% of patients had more than one seizure type. EEG, CT brain, MRI brain and neuropsychological evaluation were obtained in 81.2%, 61.7%, 17.0% and 2.2% of patients, respectively. The etiology of epilepsy was cryptogenic in 59.9%, symptomatic in 35.1% and idiopathic in 3.9%; the commonest were intracranial infection, cerebral vascular disease, cranial trauma and perinatal insult. Phenytoin, carbamazepine and valproate were the most frequently used drugs and 25.9% of patients were taking more than two drugs. 48.3% of patients had active seizures in the past six months and 26.4% were considered to have unsatisfactory control of their epilepsy. Medical refractoriness of epilepsy was associated with a history of perinatal insult, intracranial infection, congenital brain malformation, intracranial neoplasm, cerebral vascular disease, hippocampal sclerosis, mental retardation and a history of status epilepticus (P < 0.05).

CONCLUSION

In this local cohort of adult patients with epilepsy under specialist care, there were a considerable number of patients falling into the category of cryptogenic epilepsy. Risk factors associated with medical refractoriness are similar to previous studies.

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.

Knowledge of stroke in Hong Kong Chinese

A random telephone survey on knowledge of stroke was conducted in 1, 238 Hong Kong Chinese. Most respondents realized that effective treatment was available, that stroke was preventable and that it could be fatal or disabling. Sudden unilateral limb weakness, sudden speech and language disturbances, and sudden vertigo and clumsiness were better recognized than other warning symptoms of stroke. A slightly better recognition of symptoms of stroke was seen in those with a belief of knowing about stroke, providing a correct description of stroke, those with a positive household history of stroke and those with a better knowledge of potential risk factors. Most respondents would choose desirable actions if stroke was suspected in their family members or themselves. Friends and relatives, newspapers and magazines, and mass media provided the major sources of their knowledge.

Tuberculosis meningitis in Hong Kong: experience in a regional hospital

Tuberculous meningitis (TBM) remains common in Hong Kong. From January 1996 to June 1997, 11 adult patients with TBM presented to Queen Mary Hospital, a regional hospital in Hong Kong. The annual incidence of TBM was estimated at 1.8 per 100,000 population. Nine patients were local Chinese, and only one patient had the acquired immune-deficiency syndrome (AIDS). In contrast to the classical presentation as a chronic indolent disease, our patients presented acutely: the mean duration from onset of symptoms to presentation was 4.8 days (range 0-10). The most common presenting symptoms were headache (64%), fever (46%), or both (36%), with focal deficits occurring in 64% of patients. Cerebrospinal fluid (CSF) culture and polymerase chain reaction (PCR) were positive in 30% and 29% of cases. Mean CSF cell count, protein and glucose levels were 340 x 10(6)/L, 267 mg/dL, and 2.3 mmol/L, respectively. Extra-neural tuberculosis occurred in 46% of cases. All patients survived and responded to treatment. Drug-induced hepatotoxicity was common; 64% of patients developed biochemical hepatitis.

Design of a high-flux and high-resolution VUV bending-magnet beamline

A high-flux and high-resolution VUV beamline (4-40 eV) has been designed and is under construction at SRRC. This beamline, which collects 50 mrad of horizontal radiation, uses a 6 m cylindrical-grating monochromator with an incident angle of 70 degrees instead of the conventional normal-incidence-monochromator (NIM) design. Special features, such as movable entrance slit, bendable vertical focusing mirror and movable curved exit slit, are employed to enhance greatly the beamline performance. With both slit openings set at 10 micro m, the energy-resolving power can reach as high as 70000. Photon fluxes of 1 x 10(13) and 1 x 10(10) photons s(-1) are calculated for energy-resolving powers of 1000 and 40000, respectively. The best image size at the sample position is smaller than 0.45 x 0.2 mm.

A high-performance double-crystal monochromator soft X-ray beamline

A high-performance double-crystal-monochromator soft X-ray (DCMSX) beamline has been constructed at the Synchrotron Radiation Research Center (SRRC). This beamline delivers monochromatic photon beams with energies from 1 to 9 keV and a resolving power (E/DeltaE) of up to 7000. This beamline provides users with an opportunity to study many important materials, such as high-T(c) superconductors, magnetic materials, catalysts, super-alloy compounds etc. Excellent EXAFS and NEXFS spectra have been routinely obtained from this beamline. Several interesting research projects are currently being conducted at this beamline. All the results show that this beamline has been constructed to meet its design goals.

A high-performance wide-range beamline for elliptically polarized undulator source

A high-performance wide-range beamline has been designed for monochromatizing circularly polarized photons with energies from 10 to 1400 eV. A grazing SGM-based beamline with two entrance slits has been employed to optimize the performance. The degree of the circular polarization affected by the beamline optics has been analysed. The horizontal and vertical refocusing mirrors have been specially arranged to improve greatly the polarization degree in the low-energy region. By connecting this beamline to a high-efficiency elliptically polarized undulator, this beamline should be able to provide, in the entire energy range, intensive and high-resolution photons of a high degree of circular polarization.

A unique high-performance wide-range (10-1500 eV) spherical grating monochromator beamline

A wide-spectral-range high-performance 6 m-spherical grating monochromator (6 m-SGM) beamline has been designed and is under construction at SRRC. Two different entrance slits, instead of additional mirrors, are used to optimize the overall performance. Six gratings are used to cover photon energies from 10 to 1500 eV. Movable entrance slits and bendable vertical focusing mirrors are used to enhance further the beamline performance. A bendable horizontal focusing mirror is used to improve the resolution and to focus the photon beam at the experimental station immediately after the exit slit. Several end-stations can be installed at the same time to utilize the beam time fully. The expected energy-resolving power, with both slit openings set at 10 micro m, is up to 15 000 and 40 000 for the high- and low-energy branches, respectively. A photon flux of 1 x 10(11) photons s(-1) can be obtained with an energy-resolving power of 20 000.

Endothelial cell binding by human polyclonal anti-DNA antibodies: relationship to disease activity and endothelial functional alterations

Polyclonal anti-dsDNA and anti-ssDNA antibodies (PoAb) that showed significant binding to human umbilical vein endothelial cells (HUVEC) were isolated from eight patients with systemic lupus erythematosus (SLE). Anti-dsDNA PoAbs from five patients and anti-ssDNA PoAbs from seven patients demonstrated enhanced binding to HUVEC during active disease, compared with PoAbs obtained from corresponding patients during remission. Reduction of the DNA content in the PoAb preparations by DNase treatment was associated with enhanced binding to HUVEC in 20 of 32 PoAbs tested, which included 75% 'active disease' PoAbs, and with reduced binding to HUVEC in three of 32 PoAbs tested, all obtained during remission. Such altered endothelial cell binding was reversed with DNA reconstitution. Binding of the remaining nine PoAbs to HUVEC was not altered by variations in their DNA content. Induced plasma membrane expression of E-selectin, but reduced expression of vascular cell adhesion molecule-1 (VCAM-1) by HUVEC, was observed following incubation of HUVEC with 'active disease' PoAbs from three and two of the eight patients, respectively. PoAbs and serum samples from two of the eight patients during active disease induced von Willebrand factor release from HUVEC, which was not observed during remission. We conclude that anti-DNA antibodies from selected patients with SLE can bind to endothelial cells. Correlation between cellular binding and disease activity suggests that such binding of anti-DNA antibodies to endothelial cells could be of pathogenic significance. Preliminary data also suggest that the expression of adhesion molecules and haemostatic factor(s) by endothelial cells may be modified following their binding by anti-DNA antibodies.