Ultrasound Measurement of Rectus Femoris Muscle Parameters for Discriminating Sarcopenia in Community-Dwelling Adults.

OBJECTIVES: Sarcopenia patients require more medical attention and caretaking. As such, early detection of sarcopenia and appropriate interventions are crucial for decreasing medical costs and meeting the challenges of aging populations. The aim of the present study was to develop a reliable and accurate model to estimate muscle mass using ultrasound-derived parameters from the rectus femoris (RF), referenced by dual-energy X-ray absorptiometry. METHODS: Cross-sectional study was performed. The study patients were recruited by Taipei Veterans General Hospital (No. 2016-07-013C) between 2016 and 2019. A total of 91 community-dwelling adults (35 men and 56 women) were enrolled in this study. Ultrasound measurements of RF muscle thickness (MT), cross-sectional area (CSA), and muscle volume (MV) were performed in B-mode. Muscle strength and physical performance were also examined. Multivariate linear regression was used to build models for the prediction of appendicular skeletal muscle index (ASMI) based on MT, CSA, and MV values. The accuracy of ultrasound RF measurements for predicting sarcopenia was evaluated by using receiver operating characteristic (ROC) curve analysis. RESULTS: The regression equations used for ASMI prediction (adjusted body mass index, sex, and leg length) had high precision and low error. Moreover, the MV model results were close to those of the CSA model and higher than those of the MT model. The ROC analysis showed that both MV and CSA had excellent discrimination when assessing sarcopenia (AUC = 0.83 and 0.81, respectively), whereas MT showed acceptable discrimination (AUC = 0.73). CONCLUSIONS: Ultrasound-derived RF MV was accurate when predicting ASMI and diagnosing sarcopenia in community-dwelling adults.

Validity of the Osteoarthritis Research Society International (OARSI) recommended performance-based tests of physical function in individuals with symptomatic Kellgren and Lawrence grade 0-2 knee osteoarthritis.

BACKGROUND: Performance-based physical tests have been widely used as objective assessments for individuals with knee osteoarthritis (KOA), and the core set of tests recommended by the Osteoarthritis Research Society International (OARSI) aims to provide reliable, valid, feasible and standardized measures for clinical application. However, few studies have documented their validity in roentgenographically mild KOA. Our goal was to test the validity of five performance-based tests in symptomatic KOA patients with X-ray findings of Kellgren and Lawrence (K-L) grade 0-2. METHODS: We recruited a convenience sample of thirty KOA patients from outpatient clinics and 30 age- and sex-matched asymptomatic controls from the community. They performed five OARSI-recommended physical tests and the KOA group answered the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index. The tests included the 9-step stair-climbing test (9 s-SCT), timed up and go (TUG) test, 30-second chair-stand test (30sCST), 40-m fast walking-test (40MFPW) and 6-minute walking test (6MWT). The discriminant validity of these physical tests were assessed by comparisons between the KOA and control groups, receiver operating curve and multivariate logistic regression analysis. The convergent/divergent validity was assessed by correlation between the physical tests results and the three subscale scores of the WOMAC in the KOA group. RESULTS: The KOA group had significantly worse performance than the control group. The percentage of difference was the largest in the 9 s-SCT (57.2%) and TUG tests (38.4%). Meanwhile, Cohen's d was above 1.2 for the TUG test and 6MWT (1.2 ~ 2.0), and between 0.8 and 1.2 for the other tests. The areas under the curve to discriminate the two groups were mostly excellent to outstanding, except for the 30sCST. Convergent validity was documented with a moderate correlation between the 9 s-SCT and the physical function (WOMAC-PF) subscale scores (Spearman's ρ = 0.60). CONCLUSIONS: The OARSI recommended core set was generally highly discriminative between people with K-L grade 0-2 KOA and their controls, but convergent/divergent validity was observed only in the 9 s-SCT. Further studies are required to evaluate the responsiveness of these tests and understand the discordance of physical performance and self-reported measures.

Assessment System for Predicting Maximal Safe Range for Heel Height by Using Force-Sensing Resistor Sensors and Regression Models.

Women often wear high-heeled shoes for professional or esthetic reasons. However, high-heeled shoes can cause discomfort and injury and can change the body's center of gravity when maintaining balance. This study developed an assessment system for predicting the maximal safe range for heel height by recording the plantar pressure of participants' feet by using force-sensing resistor (FSR) sensors and conducting analyses using regression models. Specifically, 100 young healthy women stood on an adjustable platform while physicians estimated the maximal safe height of high-heeled shoes. The collected FSR data combined with and without personal features were analyzed using regression models. The experimental results showed that the regression model based on the pressure data for the right foot had better predictive power than that based on data for the left foot, regardless of the module. The model with two heights had higher predictive power than that with a single height. Furthermore, adding personal features under the condition of two heights afforded the best predictive effect. These results can help wearers choose maximal safe high-heeled shoes to reduce injuries to the bones and lower limbs.

Design of a Multi-Sensor System for Exploring the Relation between Finger Spasticity and Voluntary Movement in Patients with Stroke.

A novel wearable multi-sensor data glove system is developed to explore the relation between finger spasticity and voluntary movement in patients with stroke. Many stroke patients suffer from finger spasticity, which is detrimental to their manual dexterity. Diagnosing and assessing the degrees of spasticity require neurological testing performed by trained professionals to estimate finger spasticity scores via the modified Ashworth scale (MAS). The proposed system offers an objective, quantitative solution to assess the finger spasticity of patients with stroke and complements the manual neurological test. In this work, the hardware and software components of this system are described. By requiring patients to perform five designated tasks, biomechanical measurements including linear and angular speed, acceleration, and pressure at every finger joint and upper limb are recorded, making up more than 1000 features for each task. We conducted a preliminary clinical test with 14 subjects using this system. Statistical analysis is performed on the acquired measurements to identify a small subset of features that are most likely to discriminate a healthy patient from patients suffering from finger spasticity. This encouraging result validates the feasibility of this proposed system to quantitatively and objectively assess finger spasticity.

Impact of post-sepsis cardiovascular complications on mortality in sepsis survivors: a population-based study.

BACKGROUND: It remains unclear whether sepsis-related cardiovascular complications have an adverse impact on survival independent of pre-existing comorbidities. To investigate the survival impact of post-sepsis cardiovascular complications among sepsis survivors, we conducted a population-based study using the National Health Insurance Database of Taiwan. METHODS: We identified sepsis patients from the National Health Insurance Research Database of Taiwan using ICD-9-CM codes involving infection and organ dysfunction between 2000 and 2011. Post-sepsis incident myocardial infarction (MI) and stroke were ascertained by ICD-9-CM codes and antiplatelet treatment. We constructed a non-sepsis comparison cohort using propensity score matching to ascertain the association between sepsis and cardiovascular complications. Furthermore, we compared the 180-day mortality and 365-day mortality between patients surviving sepsis with or without post-sepsis MI or stroke within 70 days of hospital discharge. We constructed Cox regression models adjusting for pre-existing comorbidities to evaluate the independent survival impact of post-sepsis MI or stroke among sepsis survivors. RESULTS: We identified 42,316 patients hospitalized for sepsis, from which we matched 42,151 patients 1:1 with 42,151 patients hospitalized without sepsis. Compared to patients hospitalized without sepsis, patients hospitalized with sepsis had an increased risk of MI or stroke (adjusted odds ratio 1.72, 95% CI 1.60-1.85). Among 42,316 patients hospitalized for sepsis, 486 (1.15%) patients developed incident stroke and 108 (0.26%) developed incident MI within 70 days of hospital discharge. Compared to sepsis survivors without cardiovascular complications, sepsis survivors with incident MI or stroke had a higher mortality rate at 180 days (11.68% vs. 4.44%, P = 0.003) and at 365 days (16.75% vs. 7.11%, P = 0.005). Adjusting for age, sex, and comorbidities, post-sepsis MI or stroke was independently associated with increased 180-day (adjusted hazard ratio [HR] 2.16, 95% CI 1.69-2.76) and 365-day (adjusted HR 1.90, 95% CI 1.54-2.32) mortality. CONCLUSIONS: Compared to sepsis patients without incident MI or stroke, sepsis patients with incident MI or stroke following hospital discharge had an increased risk of mortality for up to 365 days of follow-up. This increased risk cannot be explained by pre-sepsis comorbidities.

Can short-term effectiveness of anti-pronation taping predict the long-term outcomes of customized foot orthoses: developing predictors to identify characteristics of patients with plantar heel pain likely to benefit from customized foot orthoses.

BACKGROUND: Foot orthoses are widely used to manage plantar heel pain (PHP). However, the evidence concerning the effect of foot orthoses on PHP is not conclusive. The study aims to identify the characteristics of patients with PHP likely to achieve a positive outcome after customized foot orthoses and to verify the concept that patients who respond positively to anti-pronation taping would achieve a positive prognosis after wearing foot orthoses for six months. METHODS: This is a prospective observational cohort study. Seventy-four patients with PHP underwent a baseline examination and received anti-pronation taping to their painful feet. The taping effects on pain and function were assessed at the 7-day follow-up visit. Then, all patients received an intervention for their PHP with customized foot orthoses for six months. Outcome was assessed with a numeric pain rating scale, the patient-specific functional scale, the foot function index, and the global rating of perceived change. Significant reduction of pain, increase of function, and perception of a meaningful improvement were considered a positive response. RESULTS: Of 74 patients, 49 had a positive response to the customized foot orthosis treatment. Five predictors were identified: (1) the average pain intensity decreased by over 1.5 points with taping, (2) the range of ankle plantarflexion > 54 degrees, (3) the strength of ankle plantarflexors on the symptomatic side was equal to or stronger than that on the other side, (4) the range of hip internal rotation < 39 degrees, and (5) the range of hip external rotation > 45 degrees. The presence of three or more predictors increased the rate of achieving positive outcome from 66 to 89%. CONCLUSIONS: The predictors of customized foot orthosis outcome in patients with PHP are related to several physical measures of a lower extremity. Findings of the study can be used to screen and select patients with PHP for foot orthosis intervention. Moreover, patients who respond positively to anti-pronation taping would also benefit from the customized foot orthoses. However, since there was no control group in the current study, it is inappropriate to draw conclusions about the effectiveness of the foot orthoses treatment. TRIAL REGISTRATION: The trial was retrospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN 12617000119392 ).

Nationwide Trend of Sepsis: A Comparison Among Octogenarians, Elderly, and Young Adults.

OBJECTIVE: We aimed to compare the sepsis incidence, mortality rates, and primary sites of infection among adult, elderly, and octogenarian patients with sepsis. DESIGN: Population-based cohort study. SETTING: The entire health insurance claims data of Taiwan, which enrolled 99.8% of the 23 million Taiwanese population. PATIENTS: Sepsis patients were identified by International Classification of Diseases, 9th Edition, Clinical Modification codes for both infection and organ dysfunction from January 1, 2002, to December 31, 2012. Patients were categorized into three age groups: 1) adults (18-64 yr); 2) elderly (65-84 yr); and 3) oldest old (≥ 85 yr). The 30-day all-cause mortality was verified by a linked national death certificate database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From 2002 to 2012, we identified 1,259,578 patients with sepsis, of which 417,328 (33.1%) were adults, 652,618 (51.8%) were elderly, and 189,632 (15.1%) were oldest old. We determined that the incidence of sepsis in the oldest old was 9,414 cases per 100,000 population on 2012, which was 31-fold greater than the adult incidence (303 cases per 100,000 population) and three-fold greater than the elderly incidence (2,908 cases per 100,000 population). Despite the increasing trend in incidence, the mortality decreased by 34% for adults, 24% for elderly, and 22% for oldest old. However, systemic fungal infection was disproportionately increased in oldest old patients (1.76% annual increase) and the elderly patients (1.00% annual increase). CONCLUSION: The incidence of sepsis is disproportionately increased in elderly and oldest old patients. Despite the increasing trend in incidence, the mortality rate in geriatric patients with sepsis has decreased. However, the increased incidence of fungal infections in the geriatric population warrants further attention.

Susceptible period for cardiovascular complications in patients recovering from sepsis.

BACKGROUND: Patients are at increased risk of cardiovascular complications while recovering from sepsis. We aimed to study the temporal change and susceptible periods for cardiovascular complications in patients recovering from sepsis by using a national database. METHODS: In this retrospective population-based cohort study, patients with sepsis were identified from the National Health Insurance Research Database in Taiwan. We estimated the risk of myocardial infarction (MI) and stroke following sepsis by comparing a sepsis cohort to a matched population and hospital control cohort. The primary outcome was first occurrence of MI or stroke requiring admission to hospital during the 180-day period following discharge from hospital after sepsis. To delineate the risk profile over time, we plotted the weekly risk of MI and stroke against time using the Cox proportional hazards model. We determined the susceptible period by fitting the 2 phases of time-dependent risk curves with free-knot splines, which highlights the turning point of the risk of MI and stroke after discharge from the hospital. RESULTS: We included 42 316 patients with sepsis; stroke developed in 831 of these patients and MI developed in 184 within 180 days of discharge from hospital. Compared with population controls, patients recovering from sepsis had the highest risk for MI or stroke in the first week after discharge (hazard ratio [HR] 4.78, 95% confidence interval [CI] 3.19 to 7.17; risk difference 0.0028, 95% CI 0.0021 to 0.0034), with the risk decreasing rapidly until the 28th day (HR 2.38, 95% CI 1.94 to 2.92; risk difference 0.0045, 95% CI 0.0035 to 0.0056) when the risk stabilized. In a repeated analysis comparing the sepsis cohort with the nonsepsis hospital control cohort, we found an attenuated but still marked elevated risk before day 36 after discharge (HR 1.32, 95% CI 1.15 to 1.52; risk difference 0.0026, 95% CI 0.0013 to 0.0039). The risk of MI or stroke was found to interact with age, with younger patients being associated with a higher risk than older patients (interaction p = 0.0004). INTERPRETATION: Compared with the general population with similar characteristics, patients recovering from sepsis had a markedly elevated risk of MI or stroke in the first 4 weeks after discharge from hospital. More close monitoring and pharmacologic prevention may be required for these patients at the specified time.

Short-term effect of ultrasound-guided low-molecular-weight hyaluronic acid injection on clinical outcomes and imaging changes in patients with rheumatoid arthritis of the ankle and foot joints. A randomized controlled pilot trial.

To determine whether hyaluronic acid (HA) injection into rheumatoid arthritis ankles and feet can achieve improvement in foot function and reduce synovial hyper-vascularization. Forty-four patients with RA having unilateral or bilateral painful ankle and foot involvement (N = 75) were studied. All the patients were randomized to receive HA (N = 40) or lidocaine (LI) (N = 35) injection at 2-week intervals; Clinical assessments were performed using a visual analog scale (VAS) and foot function index (FFItotal) including subscales of pain (FFIpain) before injection at baseline, 4 weeks (first evaluation) and 12 weeks (secondary evaluation). Imaging evaluation based on color Doppler ultrasound (CDUS) and synovitis scores was performed simultaneously. HA injection improved the VAS score (p = .009), FFIpain (p = .041), and FFItotal (p = .032) considerably more than LI injections did at the first evaluation. The CDUS values at first evaluation (p = .005) and secondary evaluation (p < .001) decreased significantly compared with the base line values. HA injections reduced the CDUS values of more than half of the joints (54%, p = .042) while the control group exhibited no change (20%, p = .56). However, HA injection did not reduce the CDUS values more than LI injection did. Regarding the evaluation of synovial hypertrophy, no significant difference was observed between or within the groups in the synovitis scores. HA injection improved short-term foot function and pain reduction. HA injection may have a modest effect in reducing synovial hyper-vascularization. Further large-scale study is warranted to confirm this result.

Use of bisphosphonates and the risk of osteonecrosis among cancer patients: a systemic review and meta-analysis of the observational studies.

PURPOSE: This study aims to systematically review observational studies evaluating the use of bisphosphonates (BPs) and risk of osteonecrosis of the jaw (ONJ) among cancer patients. METHODS: PubMed, Embase, and Cochrane Library were screened from database inception to Aug 2012. Two reviewers independently identified cohort and case-control studies evaluating the use of oral or intravenous (IV) BPs and the risk of ONJ and extracted the characteristics of the studies and risk estimates. Pooled estimates of odds ratios and 95 % confidence intervals were derived by random effects meta-analysis. Subgroup analyses were carried out according to patients' characteristics and route of BP use. RESULTS: We identified eight studies, including 1,389 cases and 569,620 controls. Use of BPs was associated with a significantly increased risk of ONJ (odds ratio (OR) 4.25; 95 % confidence interval (CI) 3.67-5.36; I (2) = 0 %). The summary OR was 4.22 (95 % CI 3.21-5.54; I (2) = 0 %) for adjusted studies. IV BPs were associated with higher risk (OR 4.27; 95 % CI 3.38-5.40; I (2) = 0 %) than oral BPs (OR 1.18; 95 % CI 0.89-1.56; I (2) = 0 %). Hospital-based studies were associated with higher risk estimates than population-based studies. CONCLUSION: The available evidence suggests that use of BPs in cancer patients is associated with a substantial risk for ONJ. Patients receiving IV BP are at the highest risk. It is important to assess oral health before initiating therapy and to avoid dental procedures during the active phase of intravenous BP therapy.

Use of serum procalcitonin to detect bacterial infection in patients with autoimmune diseases: a systematic review and meta-analysis.

OBJECTIVE: To systematically review evidence of the accuracy of the procalcitonin test for diagnosis of bacterial infection in patients with autoimmune disease. METHODS: The major databases Medline, EMBase, and the Cochrane Library were searched for studies published between January 1966 and October 2011 that evaluated procalcitonin, alone or in comparison with other laboratory markers such as C-reactive protein (CRP), as a diagnostic marker for bacterial infection in patients with autoimmune disease and provided sufficient data to permit construction of 2 × 2 tables. RESULTS: Nine studies were included in the final meta-analysis. The area under the summary receiver operating characteristic curve values were 0.91 (95% confidence interval [95% CI] 0.88-0.93) for procalcitonin and 0.81 (95% CI 0.78-0.84) for CRP. In general, testing for procalcitonin was highly specific for identifying infectious complications, although it was not as sensitive as testing for CRP. Pooled sensitivity was 0.75 (95% CI 0.63-0.84) for procalcitonin tests and 0.77 (95% CI 0.67-0.85) for CRP tests. Pooled specificity was 0.90 (95% CI 0.85-0.93) for procalcitonin tests and 0.56 (95% CI 0.25-0.83) for CRP tests. The positive likelihood ratio for procalcitonin (7.28 [95% CI 5.10-10.38]) was sufficiently high to qualify procalcitonin testing as a rule-in diagnostic tool, while the negative likelihood ratio (0.28 [95% CI 0.18-0.40]) was not sufficiently low to qualify procalcitonin testing as a reliable rule-out diagnostic tool. CONCLUSION: Procalcitonin has higher diagnostic value than CRP for the detection of bacterial sepsis in patients with autoimmune disease, and the test for procalcitonin is more specific than sensitive. A procalcitonin test is not recommended to be used in isolation as a rule-out tool.

Discriminative Changes in Sitting and Standing Postural Steadiness in Patients With Chronic Low Back Pain.

Postural control is reduced in patients with low back pain (LBP), which is considered an important factor attributing to the chronicity of LBP and a target for treatment. It is proposed that the changes in postural steadiness in sitting reflect the trunk control better than those in standing, but the previous study results are inconsistent. Thus, this study aimed to compare trunk sway parameters during standing and sitting between patients with chronic LPB (CLBP) and controls using a tracker-based posturography to record the trunk displacement trajectories at the lumbar level (TD [Formula: see text]. A total of 64 participants (32 patients with CLBP and 32 pain-free controls) were included in this study. The postural sway was measured under four conditions, sitting or standing on unstable surface, with eyes open or closed. The TDL parameters were compared between the two groups to explore their discriminative ability. The CLBP group had more body sway than the control group, characterized by several TDL parameters in sitting with eyes closed and standing with eyes open. The TDL parameters with the highest area under the curve according to the receiver operating characteristic curve analysis were the root mean square distance and mean frequency in the medial-lateral direction obtained in the sitting with eyes closed. In conclusion, we confirmed the advantage of using sitting posturographic parameters as a sensitive measure to detect impaired trunk control in patients with CLBP. The results would help choose sensitive outcome measures to reflect the postural control of patients with LBP.

Comparison of the test characteristics of procalcitonin to C-reactive protein and leukocytosis for the detection of serious bacterial infections in children presenting with fever without source: a systematic review and meta-analysis.

STUDY OBJECTIVE: We determine the usefulness of the procalcitonin for early identification of young children at risk for severe bacterial infection among those presenting with fever without source. METHODS: The design was a systematic review and meta-analysis of diagnostic studies. Data sources were searches of MEDLINE and EMBASE in April 2011. Included were diagnostic studies that evaluated the diagnostic value of procalcitonin alone or compared with other laboratory markers, such as C-reactive protein or leukocyte count, to detect severe bacterial infection in children with fever without source who were aged between 7 days and 36 months. RESULTS: Eight studies were included (1,883 patients) for procalcitonin analysis, 6 (1,265 patients) for C-reactive protein analysis, and 7 (1,649 patients) for leukocyte analysis. The markers differed in their ability to predict serious bacterial infection: procalcitonin (odds ratio [OR] 10.6; 95% confidence interval [CI] 6.9 to 16.0), C-reactive protein (OR 9.83; 95% CI 7.05 to 13.7), and leukocytosis (OR 4.26; 95% CI 3.22 to 5.63). The random-effect model was used for procalcitonin analysis because heterogeneity across studies existed. Overall sensitivity was 0.83 (95% CI 0.70 to 0.91) for procalcitonin, 0.74 (95% CI 0.65 to 0.82) for C-reactive protein, and 0.58 (95% CI 0.49 to 0.67) for leukocyte count. Overall specificity was 0.69 (95% CI 0.59 to 0.85) for procalcitonin, 0.76 (95% CI 0.70 to 0.81) for C-reactive protein, and 0.73 (95% CI 0.67 to 0.77) for leukocyte count. CONCLUSION: Procalcitonin performs better than leukocyte count and C-reactive protein for detecting serious bacterial infection among children with fever without source. Considering the poor pooled positive likelihood ratio and acceptable pooled negative likelihood ratio, procalcitonin is better for ruling out serious bacterial infection than for ruling it in. Existing studies do not define how best to combine procalcitonin with other clinical information.

Diagnostic role of procalcitonin in patients with suspected appendicitis.

BACKGROUND: The aim of this study was to assess the diagnostic value of procalcitonin (PCT) in emergency department (ED) patients with suspected appendicitis. METHODS: A prospective observational study was carried out in the emergency department of a university hospital between July 2007 and June 2008. Adult patients who presented to the ED with clinically suspected appendicitis were enrolled. Each patient underwent serum PCT, C-reactive protein (CRP), and Alvarado score evaluation on admission. The results of these three measurements were analyzed in relation to the final diagnosis determined by histopathological findings or compatible computed tomography findings. RESULTS: Of the 214 study patients, 113 (52.8 %) had a confirmed diagnosis of appendicitis and 58 had complicated appendicitis (phlegmon, perforation, or gangrene). For the diagnosis of appendicitis, the area under the receiving operating characteristic (ROC) curve is 0.74 for Alvarado score, 0.69 for PCT, and 0.61 for CRP. Overall, the Alvarado score has the best discriminative capability among the three tested markers. We adopted two cutoff point approaches to harness both ends of the diagnostic value of a biomarker. PCT levels were significantly higher in patients with complicated appendicitis. For diagnosis of complicated appendicitis, a cutoff value of 0.5 ng/mL had a sensitivity of 29 % and a specificity of 95 %, while a cutoff value of 0.05 ng/ml had a sensitivity of 85 % and a specificity of 30 % in diagnosing complicated appendicitis. For those with a PCT value in the gray zone, clinical findings may play a more important role. CONCLUSION: The study does not support the hypothesis that the PCT test may be useful for screening ED patients for appendicitis. However, determination of the PCT level may be useful for risk assessment of ED patients with suspected complicated appendicitis.

Development of a Smartphone-Based mHealth Platform for Telerehabilitation.

Telerehabilitation is becoming increasingly valuable as a method for expanding medical services. The smartphone-based mHealth platform (SMPT) has been developed to provide high-quality remote rehabilitation through a smartphone and inertial measurement units. The SMPT uses smartphone as a main platform with connection to medical backend server to provide telerehabilitation. Patients would be referred to therapists to receive a tutorial of exercise technique prior to conducting their home exercise. Once patients begin their home exercises, they can report any problems instantly through the SMPT. The medical staff can adjust the exercise program according to patient feedback and the data collected by the SMPT. After completing the exercise program, patients visit their clinician for re-evaluation. A Service User Technology Acceptability Questionnaire from both medical professional and public perspective revealed a high level of agreement on enhanced care, increased accessibility, and satisfaction and a moderate level of agreement on the use of this platform as a substitute for traditional rehabilitation. Concerns about privacy and discomfort were low in the medical professional and public groups. Concerns about care personnel were also significantly different between the two groups. The SMPT is a promising system for providing telerehabilitation as an adjunct to traditional rehabilitation, which may result in improved outcomes compared with those achieved when using traditional rehabilitation alone.

An Intelligent Motor Assessment Method Utilizing a Bi-Lateral Virtual-Reality Task for Stroke Rehabilitation on Upper Extremity.

Virtual reality (VR) has been widely adopted by therapists to provide rich motor training tasks. Time series data of motion trajectory accompanied with the interaction of VR system may contain important clues in regard to the assessment of motor function, however, clinical evaluation scales such as Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), and Test D'évaluation Des Membres Supérieurs Des Personnes Âgées (TEMPA) are highly depended in clinic. Further, there is not yet an assessment method that simultaneously consider motion trajectory and clinical evaluation scales. The objective of this study is to establish an evidence-based assessment model by machine-learning method that integrated motion trajectory of a VR task with clinical evaluation scales. In this study, a VR system for upper-limb motor training was proposed for stroke rehabilitation. Clinical trials with 20 stroke patients were performed. A variety of motor indicators that derived via motion trajectory were proposed. The correlations between motor indicators and clinical evaluation scales were examined. Further, motor indicators were integrated with evaluation scales to develop a machine-learning based model that represents an evidence-based motor assessment approach. Clinical evaluation scales, FMA, TEMPA and WMFT, were significantly progressed. A few motor indicators were found significantly correlated with clinical evaluation scales. The accuracy of machine-learning based assessment model was up to 86%. The proposed VR system is validated to be effective in motor rehabilitation. Motor indicators derived from motor trajectory were with potential for clinical motor assessment. Machine learning could be a promising tool to perform automatic assessment. Clinical and Translational Impact Statement-A VR task for motor rehabilitation was exanimated via clinical trials. Integrating motor indices with clinical assessment, a machine-learning model with accuracy of 86% was developed to evaluate motor function.

Comparison of clinical characteristics and performance of pneumonia severity score and CURB-65 among younger adults, elderly and very old subjects.

BACKGROUND: Age-related alterations in the clinical characteristics and performance of severity scoring systems for community-acquired pneumonia (CAP) are unknown. METHODS: Consecutive patients with CAP presenting to the emergency department were prospectively studied. Patients were classified as younger adults (age 18-64 years), elderly (age 65-84 years) and very old subjects (age ≥85 years). Clinical characteristics, complications, outcomes and validity of the pneumonia severity index (PSI) and CURB-65 categories were compared across these three age categories. RESULTS: Analysis involved 348 (35.3%) younger adult patients, 438 (44.3%) elderly patients and 201 (20.0%) very old patients. Compared with younger adults, elderly and very old patients had a higher burden of comorbidities and a higher incidence of CAP-related complications. The 30-day mortality rate was 5.2% in younger adults, 7.1% in elderly patients and 9.5% in very old patients. The area under the ROC curve (AUCs) for PSI were 0.87 (95% CI 0.77 to 0.97), 0.85 (95% CI 0.803 to 0.897) and 0.69 (95% CI 0.597 to 0.787) and the AUCs for CURB-65 were 0.80 (95% CI 0.67 to 0.93), 0.73 (95% CI 0.65 to 0.82) and 0.60 (95% CI 0.47 to 0.73) in the younger adult, elderly and very old patients, respectively. A modified PSI or CURB-65 excluding the age variable increased the AUC in most age categories. There was no significant effect of age on 30-day mortality after adjusting for other PSI or CURB-65 variables. CONCLUSION: Elderly patients with CAP have more atypical clinical manifestations and worse outcomes. The underperformance of the PSI in elderly patients may be due to the inappropriate weight given to the age variable. A modification of the cut-off point for PSI or CURB-65 to define severe pneumonia may improve the score performance in elderly patients.

Evaluation of the value of rapid D-dimer test in conjunction with cardiac troponin I test for early risk stratification of myocardial infarction.

We sought to determine the diagnostic value of a D-dimer test for myocardial infarction (MI). The prospective cohort study was carried in the ED of a university hospital. All included patients were tested for D-dimer and cardiac troponin I (cTnI) on ED admission and additional cTnI 6 h later. AMI was retrospectively confirmed by employing the ESC-ACC-AHA-WHF 2007 universal definition. The discriminative value of D-dimer test was assessed by ROC curve analysis. Multivariate analysis was used to identify independent risk factors associated with D-dimer elevation other than MI. A total of 178 patients were included in this study. Median D-dimer levels were significantly higher in MI patients. A D-dimer value greater than 200 ng/ml was significantly associated with MI. When used alone, the test has a high sensitivity of 91.8% but a low specificity of 23.9%. Combined use of cTnI and D-dimer tests raised the sensitivity to 98.4% and helped early triage a subgroup of low risk patients. However, the test had the downside of 58% false positives. High false positives could be partly explained by the high prevalence of underlying hypercoagulable comorbidities. Diabetes mellitus with chronic renal insufficiency was identified as the strongest risk factor associated with D-dimer elevation in patients without MI. D-dimer test alone has a low diagnostic value for MI. Co-existing hypercoagulable conditions may confound the results. Combining cTnI and D-dimer tests enables early identification a low risk group of patients for MI at the cost of high false positives.

Synchrony Between Default-Mode and Sensorimotor Networks Facilitates Motor Function in Stroke Rehabilitation: A Pilot fMRI Study.

Stroke is the most common cause of complex disability in Taiwan. After stroke onset, persistent physical practice or exercise in the rehabilitation procedure reorganizes neural assembly for reducing motor deficits, known as neuroplasticity. Neuroimaging literature showed rehabilitative effects specific to the brain networks of the sensorimotor network (SMN) and default-mode network (DMN). However, whether between-network interactions facilitate the neuroplasticity after stroke rehabilitation remains a mystery. Therefore, we conducted the longitudinal assessment protocol of stroke rehabilitation, including three types of clinical evaluations and two types of functional magnetic resonance imaging (fMRI) techniques (resting state and grasp task). Twelve chronic stroke patients completed the rehabilitation protocol for at least 24 h and finished the three-time assessments: before, after rehabilitation, and 1 month after the cessation of rehabilitation. For comparison, age-matched normal controls (NC) underwent the same fMRI evaluation once without repeated measure. Increasing scores of the Fugl-Meyer assessment (FMA) and upper extremity performance test reflected the enhanced motor performances after the stroke rehabilitation process. Analysis of covariance (ANCOVA) results showed that the connections between posterior cingulate cortex (PCC) and iM1 were persistently enhanced in contrast to the pre-rehabilitation condition. The interactions between PCC and SMN were positively associated with motor performances. The enhanced cross-network connectivity facilitates the motor recovery after stroke rehabilitation, but the cross-network interaction was low before the rehabilitation process, similar to the level of NCs. Our findings suggested that cross-network connectivity plays a facilitatory role following the stroke rehabilitation, which can serve as a neurorehabilitative biomarker for future intervention evaluations.

Wearable Sensors Integrated with Virtual Reality: A Self-Guided Healthcare System Measuring Shoulder Joint Mobility for Frozen Shoulder.

Frozen shoulder is a common clinical shoulder condition. Measuring the degree of shoulder joint movement is crucial to the rehabilitation process. Such measurements can be used to evaluate the severity of patients' condition, establish rehabilitation goals and appropriate activity difficulty levels, and understand the effects of rehabilitation. Currently, measurements of the shoulder joint movement degree are typically conducted by therapists using a protractor. However, along with the growth of telerehabilitation, measuring the shoulder joint mobility on patients' own at home will be needed. In this study, wireless inertial sensors were combined with the virtual reality interactive technology to provide an innovative shoulder joint mobility self-measurement system that can enable patients to measure their performance of four shoulder joint movements on their own at home. Pilot clinical trials were conducted with 25 patients to confirm the feasibility of the system. In addition, the results of correlation and differential analyses compared with the results of traditional measurement methods exhibited a high correlation, verifying the accuracy of the proposed system. Moreover, according to interviews with patients, they are confident in their ability to measure shoulder joint mobility themselves.