Novel Wireless Bioimpedance Device for Segmental Lymphedema Analysis Post Dual-Site Free Vascularized Lymph Node Transfer: A Prospective Cohort Study.

An innovative wireless device for bioimpedance analysis was developed for post-dual-site free vascularized lymph node transfer (VLNT) evaluation. Seven patients received dual-site free VLNT for unilateral upper or lower limb lymphedema. A total of 10 healthy college students were enrolled in the healthy control group. The device was applied to the affected and unaffected limbs to assess segmental alterations in bioimpedance. The affected proximal limb showed a significant increase in bioimpedance at postoperative sixth month (3.3 [2.8, 3.6], p = 0.001) with 10 kHz currents for better penetration, although the difference was not significant (3.3 [3.3, 3.8]) at 1 kHz. The bioimpedance of the affected distal limb significantly increased after dual-site free VLNT surgery, whether passing with the 1 kHz (1.6 [0.7, 3.4], p = 0.030, postoperative first month; 2.8 [1.0, 4.2], p = 0.027, postoperative third month; and 1.3 [1.3, 3.4], p = 0.009, postoperative sixth month) or 10 kHz current ((1.4 [0.5, 2.7], p = 0.049, postoperative first month; 3.2 [0.9, 6.3], p = 0.003, postoperative third month; and 3.6 [2.5, 4.1], p < 0.001, postoperative sixth month). Bioimpedance alterations on the affected distal limb were significantly correlated with follow-up time (rho = 0.456, p = 0.029 detected at 10 kHz). This bioimpedance wireless device could quantitatively monitor the interstitial fluid alterations, which is suitable for postoperative real-time surveillance.

Associations of TNF-α and IL-6 polymorphisms with osteoporosis through joint effects and interactions with LEPR gene in Taiwan: Taichung Community Health Study for Elders (TCHS-E).

Osteoporosis (OST) is a complex multifactorial disease considered to result from interactions of multiple gene and environmental factors. Tumor necrosis factor (TNF)-α and interleukin (IL)-6 are pleiotropic cytokines essential for bone remodeling; and hormone leptin has immunomodulatory effects that stimulate the synthesis of IL-6 and TNF-α. Leptin is involved in the modulation of bone growth and turnover; and its actions are bound by leptin receptor (LEPR). Prior studies evaluated the effects of TNF-α, IL-6, and LEPR gene polymorphisms separately on bone mineral densities (BMD) or OST. In this study, we assessed the roles of TNF-α and IL-6 gene polymorphisms in OST through joint effects and interactions with LEPR gene. We also evaluated possible joint effects and interactions between these polymorphisms and physical activity. Ten tag-SNPs (rs1799964, rs1800629, rs3093662 in TNF-α; rs1880243, rs1800796, rs1554606 in IL-6; and rs1751492, rs8179183, rs1805096, rs1892534 in LEPR) were used to genotype 103 OST cases and 369 controls. BMD of lumbar spine (LS), femoral neck (FN), and total hip (TH) were measured by dual-energy X-ray absorptiometry. Our data showed that TNF-α and IL-6 polymorphisms were associated with overall and site-specific OST in both sexes, and that these associations were dependent on rs1805096 and rs1892534 genotypes of LEPR. In men, LEPR A-G-G-G haplotype was associated with FN OST (OR 4.65, 95 % CI 1.61-13.40, p = 0.004). Genotype AA/AG of LEPR rs1751492 was associated with overall and FN OST in women without physical activity, but not in women with physical activity (p < 0.05 for interaction between physical activity and LEPR rs1751492). In men, we detected significant interactions of IL-6 rs1800796 with LEPR rs1805096 and rs1892534 for FN and TH OST (all p < 0.05). Our data indicate that LEPR gene may play joint and interactive roles with TNF-α and IL-6 genes and physical inactivity in development of OST. Haplotype analyses revealed that the correlations tended to be prominent in men with FN OST.

Sarcopenia Defined by Combining Height- and Weight-Adjusted Skeletal Muscle Indices is Closely Associated With Poor Physical Performance.

OBJECTIVES: To compare muscle strength and physical performance among subjects with and without sarcopenia of different definitions. DESIGN: A population-based cross-sectional study. PARTICIPANTS: 857 community residents aged 65 years or older. METHODS: Sarcopenia was defined according to the European Working Group of Sarcopenia in Older People consensus criteria. Dual-energy X-ray absorptiometry measured lean soft tissue mass. Sarcopenic participants with low height-adjusted or weight-adjusted skeletal muscle index (SMI) were classified as having h-sarcopenia or w-sarcopenia, respectively. Combined sarcopenia (c-sarcopenia) was defined as having either h- or w-sarcopenia. The participants underwent six physical performance tests: walking speed, timed up-and-go, six-minute walk, single-leg stance, timed chair stands, and flexibility test. The strength of five muscle groups was measured. RESULTS: Participants with h-sarcopenia had lower weight, body mass index (BMI), fat mass, and absolute muscle strength (p ≤ .001); those with w-sarcopenia had higher weight, BMI, fat mass (p < .001), and low relative muscle strength (p ≤ .003). Participants with c-sarcopenia had poorer performance in all physical performance tests, whereas h-sarcopenia and w-sarcopenia were associated with poor performance in four tests. CONCLUSION: Subjects with h- and w-sarcopenia differ significantly in terms of obesity indicators. Combining height- and weight-adjusted SMIs can be a feasible method to define sarcopenia.

Diabetes mellitus and accompanying hyperlipidemia are independent risk factors for adhesive capsulitis: a nationwide population-based cohort study (version 2).

Previous case-control studies of Caucasian ethnicity have reported the association of adhesive capsulitis (AC) with diabetes mellitus (DM). To further investigate the risk of AC in subjects with DM in an Asian population, we performed the present cohort study featured the analyses of a randomly selected sub-dataset of one million individuals insured by the Taiwan National Health Insurance for the period spanning 1996-2008. The study and comparison cohorts consisted of 5,109 newly diagnosed diabetic patients and 20,473 randomly selected non-diabetic subjects aged ≥ 20 years in the year 2000. Both cohorts were followed up until December 2008 to measure AC incidence. We found that the incidence density of AC in the DM cohort was 3.08 times that of the comparison cohort (146.9 vs. 47.7 per 10,000 person-years), and rate ratios varied from 1.23 to 4.98 by categorized sociodemographic factors and comorbidity. The hazard ratio (HR) of AC for DM subjects remained significantly higher than that for non-DM subjects (p < 0.001) in all models. The HR increased in older age-groups (p < 0.001) and females (p < 0.001). Hyperlipidemia consistently increases the risk of AC in both univariate (HR = 2.67, 95% confidence interval (CI) 2.36-4.06) and multivariate analyses (HR = 1.29, 95% CI 1.11-1.49). In this eight-year study period, we found that DM and accompanying hyperlipidemia were independent risk factors for AC. The risks are higher for older-aged women. Findings in the present study help to identify high-risk patient groups to exercise early prevention of AC and enhance comprehensive care quality of DM subjects.

Risk and mortality of traumatic brain injury in stroke patients: two nationwide cohort studies.

OBJECTIVE: Patients with stroke had higher incidence of falls and hip fractures. However, the risk of traumatic brain injury (TBI) and post-TBI mortality in patients with stroke was not well defined. Our study is to investigate the risk of TBI and post-TBI mortality in patients with stroke. METHODS: Using reimbursement claims from Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study of 7622 patients with stroke and 30 488 participants without stroke aged 20 years and older as reference group. Data were collected on newly developed TBI after stroke with 5 to 8 years' follow-up during 2000 to 2008. Another nested cohort study including 7034 hospitalized patients with TBI was also conducted to analyze the contribution of stroke to post-TBI in-hospital mortality. RESULTS: Compared with the nonstroke cohort, the adjusted hazard ratio of TBI risk among patients with stroke was 2.80 (95% confidence interval = 2.58-3.04) during the follow-up period. Patients with stroke had higher mortality after TBI than those without stroke (10.2% vs 3.2%, P < .0001) with an adjusted relative risk (RR) of 1.46 (95% confidence interval = 1.15-1.84). Recurrent stroke (RR = 1.60), hemorrhagic stroke (RR = 1.68), high medical expenditure for stroke (RR = 1.80), epilepsy (RR = 1.79), neurosurgery (RR = 1.94), and hip fracture (RR = 2.11) were all associated with significantly higher post-TBI mortality among patients with stroke. CONCLUSIONS: Patients with stroke have an increased risk of TBI and in-hospital mortality after TBI. Various characteristics of stroke severity were all associated with higher post-TBI mortality. Special attention is needed to prevent TBI among these populations.

Successful aging defined by health-related quality of life and its determinants in community-dwelling elders.

BACKGROUND: Successful aging in old age is important. However, the determinants of successful aging vary across populations due to cultural differences, and only a limited number of studies have addressed these determinants in Taiwan population. This study aimed to evaluate successful aging via better physical and mental functions as well as to explore associated determinants in an elderly Taiwan population that had no impaired cognitive function. METHODS: A community-based cross-sectional survey was conducted in January 2009 in Taichung, Taiwan. A total of 903 elderly persons (≥65 years) without impaired cognitive function were enrolled. Those with physical and mental component scores in the top tertile of the Short-Form 36 were considered to be aging successfully. All participants completed a structured questionnaire and the comprehensive geriatric assessment measurements of the five components of frailty defined by Fried et al. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to evaluate the relationship between associated factors and successful aging using logistic regression analysis. RESULTS: The prevalence of successful aging was 10.4% in elders. A higher proportion of successful aging was found in non-frail (16.9%) and pre-frail elders (7.2%) than in frail elders (0.9%). Multivariate logistic regression showed pre-frail elders to be associated with lower prevalence of successful aging relative to non-frail elders (OR: 0.45; 95% CI: 0.24-0.84). Relative to those aged ≤70 years, elders aged 71-75 years were associated with a lower prevalence of successful aging (OR: 0.27; 95% CI: 0.13-0.58). Successful aging was also more likely among those able to visit relatives and friends (OR: 3.86, 95% CI: 1.09-13.61) and among those without a history of falling (OR: 4.95; 95% CI: 1.79-13.74), pain (OR: 4.04; 95% CI: 2.18-7.50), or sleep disorders (OR: 2.36; 95% CI: 1.30-4.27). CONCLUSION: Successful aging was associated with age, frail status, chronic health-related problems and psychosocial support. However, whether or not these associations are causal requires further exploration.

Longitudinal changes in swallowing function after surgery and proactive swallowing therapy for oral cancer.

BACKGROUND: This study aimed to describe and explore the longitudinal changes in swallowing function among patients with oral cancer who underwent surgery and proactive swallowing therapy from baseline to 1-year postoperation. METHODS: We retrospectively studied 118 patients over a 4.5-year duration. Swallowing functional assessment including 10-item Eating Assessment Tool (EAT-10), Functional Oral Intake Scale (FOIS), M. D. Anderson Dysphagia Inventory, and Modified Barium Swallow Impairment Profile (MBSImP™) was performed at baseline, 1-month, 6-month, and 1-year postoperatively. RESULTS: All swallowing parameters worsened 1-month postoperation. EAT-10, FOIS, and MBSImP™ oral and pharyngeal impairment scores improved significantly compared with 1-month postoperation at 6 months. Other swallowing parameters, except for weight, did not differ significantly from baseline at 6 months. The rate of tube-feeding dependency was 11.5% and 5.6% at 1 and 6 months postoperation, respectively. CONCLUSIONS: Periodic swallowing functional assessments help delineate the longitudinal changes in swallowing functional outcomes.

Clinical characteristics and electrodiagnostic features in patients with carpal tunnel syndrome, double crush syndrome, and cervical radiculopathy.

Similar unilateral neck and upper limb symptoms are often due to various entrapment neuropathies; carpal tunnel syndrome (CTS) and cervical radiculopathy (CR) are common causes among them. Therefore, we investigated the clinical characteristics and electrodiagnostic features of patients with carpal tunnel syndrome, cervical radiculopathy, and both conditions, called double crush syndrome (DCS). The medical records and electrodiagnostic reports of 866 patients with suspected CTS and CR visited a tertiary-care hospital were retrospectively analyzed. After excluding 101 patients with confounding conditions, 151 (20%) patients were diagnosed to have sole cases of CTS; 362 (47%) patients were diagnosed to have sole cases of CR; 198 (26%) patients were diagnosed to have DCS, while 54 (7%) patients had mere symptoms. Sole cases of CR had the highest incidences of neck pain, upper back pain, wrist and hand weakness. Female patients had the highest incidences of all the diseases in their sixth decade. Male patients had comparably distinguished high occurrence of all the diseases in their fifth to sixth decades. Although comparison of nerve conduction studies between patients with mere symptoms and patients with sole cases of CTS or DCS showed statistical differences, comparison between the latter two revealed no difference. We found most patients referred for electrodiagnostic studies had cervical radiculopathy. High concomitant occurrence of CTS and CR suggests cautious evaluation of patients with upper limb symptoms is important, because the management of these conditions is quite different.

Urinating in the standing position: a feasible alternative for elderly women with knee osteoarthritis.

PURPOSE: Urinating while standing is a possible alternative for elderly women with knee osteoarthritis when a sitting toilet is unavailable. We evaluated uroflowmetric characteristics and post-void residual urine volume in elderly women with knee osteoarthritis who urinated while standing. MATERIALS AND METHODS: We recruited 21 women with a mean±SD age of 65.0±4.6 years who had a knee osteoarthritis Lequesne index score of at least 6 points and were unable to maintain or found it difficult to stand up from a squat or crouch. Participants used a homemade auxiliary appliance to collect urine and drain it forward while stand voiding. Uroflowmetric data, including voided volume, and maximal and average flow rates, were recorded. Post-void residual urine volume was detected using an ultrasound bladder scanner. Participants completed a questionnaire to evaluate their attitude toward stand voiding and using the auxiliary device. RESULTS: Maximal and average flow rates, and voided and post-void residual urine volumes were not statistically different while sitting and standing. No learning curve was noted for stand voiding. Uroflowmetry patterns while standing were smooth. Of the 21 participants 17 (81%) experienced no difficulty while stand voiding. All expressed willingness to urinate while standing position if they did not have access to a satisfactorily clean toilet seat. CONCLUSIONS: Urinating while standing is a feasible option for elderly women with knee osteoarthritis who have difficulty crouching or squatting to void in public restrooms.

Reliability and validity of the Taiwan (Mandarin Chinese) version of the chronic respiratory questionnaire.

PURPOSE: The chronic respiratory disease questionnaire (CRQ) has been validated and proved useful in assessing therapies for pulmonary diseases. We translated the CRQ into a Taiwan (Mandarin Chinese) version and surveyed its validity and reliability. METHODS: The CRQ includes 20 items divided into four domains: dyspnea, fatigue, emotional function, and mastery. We followed a forward-back translation procedure to create the Taiwan version. A cross-sectional survey was conducted among outpatients with chronic obstructive pulmonary disease. Participants underwent tests including the CRQ, the medical outcomes study short form (SF-36), the St. George respiratory questionnaire (SGRQ), lung function tests (LFTs), and a graded exercise test (GET). We used Cronbach's alpha to evaluate the internal consistency of the CRQ, intraclass coefficient for test-retest reliability, and Spearman's correlation for validity. RESULTS: Thirty-six men and 4 women (mean age 67.9 ± 9.9 years) were recruited. Evidence of good internal consistency, test-retest reliability, convergent, discriminant, concurrent, and construct validity of the CRQ was shown. Spearman's correlation showed moderate-to-strong correlation between the CRQ scores and scores of the SGRQ, subscales of the SF-36, and the results of LFTs and GET. CONCLUSIONS: The Taiwan version of the CRQ shows good validity, internal consistency, and test-retest reliability.

Voiding dysfunctions in children with mental retardation.

AIMS: This study aims to evaluate the voiding disorder and lower urinary tract symptoms in mentally retarded children. METHODS: Fifty-one mentally retarded children (age 7.7 years) was assessed. A volunteer sample comprised of 36 typically developing children (age 6.4 years) served as the comparative group. All participants underwent uroflometric investigation, and residual urine was detected by sonography. Urological history including history of urinary tract infection, incontinence, frequency, and dysurea was collected. In addition, the mentally retarded group was classified according to IQ: severe mentally retarded group (IQ below 40) (n = 11), moderate mentally retarded group (IQ: 41 to 55) (n = 19), mild mentally retarded group (IQ: 56 to 70) (n = 21). Group comparisons were analyzed using Chi-square and Student's t-test. RESULTS: Of the 51 mentally retarded children, 18(35.2%) were found to have voiding dysfunction, which is significantly higher than the control group (8.3%). The incidence of urine incontinence and frequency is also significantly higher in the mentally retarded group. The comparison of the three mentally retarded subgroups showed that the severe mentally retarded group had the highest incidence of voiding dysfunction and urinary incontinence. Overall, the mentally retarded group had higher percentage of small bladder capacity. CONCLUSIONS: We concluded that mentally retarded children have a higher incidence of voiding dysfunction and incontinence than the control group. Early detection of voiding dysfunction in an objective, non-invasive manner is important in mentally retarded children, particularly those with severe cognitive impairment.

Incomplete bladder emptying in patients with stroke: is detrusor external sphincter dyssynergia a potential cause?

OBJECTIVES: To delineate the frequency, clinical risk factors, and urodynamic mechanisms of incomplete bladder emptying (IBE) among patients with recent stroke. DESIGN: Retrospective study. SETTING: Inpatient setting in the rehabilitation ward of a university hospital. PARTICIPANTS: All patients with acute stroke admitted for rehabilitation between January and December 2005, excluding those with a history of lower-urinary tract symptoms and urologic diseases. Eighty-two patients (42 women and 40 men; mean age, 65.5 y) were included. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We measured postvoid residual (PVRs) by catheterization or by using an ultrasonic bladder scanner. Twenty-five patients (30.5%) had IBE with PVRs greater than 100 mL on 2 consecutive days. Patients with IBE were evaluated by a urologist and subsequently underwent urodynamic studies. RESULTS: The presence of IBE was significantly associated with urinary tract infection (P<.001) and aphasia (P=.046). The presence of IBE was not related to sex, stroke location, nature of stroke (hemorrhagic or ischemic), history of diabetes mellitus, or previous stroke. Urodynamic studies done on 22 patients with IBE revealed acontractile detrusor in 8 patients (36%) and detrusor underactivity in 3 (14%). Eleven patients (50%) had detrusor-external sphincter dyssynergia (DESD) combined with normative detrusor function (5 patients) or detrusor hyperactivity (6 patients); all but 1 of these patients had a supratentorial lesion. The presence of DESD was associated with a longer onset-to-evaluation interval (P=.018) [corrected] and spasticity of the stroke-affected lower limb (P=.02). [corrected] Diabetes mellitus was associated with the presence of acontractile detrusor or detrusor underactivity (P=.03). CONCLUSIONS: IBE is common among patients with stroke and is caused by decreased detrusor contractility or DESD. Spasticity of the external urethral sphincter is a possible pathophysiologic mechanism of DESD.

Changes in Balance, Gait and Electroencephalography Oscillations after Robot-Assisted Gait Training: An Exploratory Study in People with Chronic Stroke.

Robot-assisted gait training (RAGT) systems offer the advantages of standard rehabilitation and provide precise and quantifiable control of therapy. We examined the clinical outcome of RAGT and analyzed the correlations between gait analysis data and event-related desynchronization (ERD) and event-related synchronization (ERS) in patients with chronic stroke. We applied the Berg balance scale (BBS) and analyzed gait parameters and the ERD and ERS of self-paced voluntary leg movements performed by patients with chronic stroke before and after undergoing RAGT. A significant change was observed in BBS (p = 0.011). We also showed preliminary outcomes of changes in gait cycle duration (p = 0.015) and in ipsilesional ERS in the low-beta (p = 0.033) and high-beta (p = 0.034) frequency bands before and after RAGT. In addition, correlations were observed between BBS and ipsilesional ERS in the alpha and low-beta bands (r = -0.52, p = 0.039; r = -0.52, p = 0.040). The study demonstrated that RAGT can improve balance and provided an idea of the possible role of brain oscillation and clinical outcomes in affecting stroke rehabilitation.

Effects of concurrent aerobic and resistance exercise in frail and pre-frail older adults: A randomized trial of supervised versus home-based programs.

BACKGROUND: This study aimed to investigate the effects of supervised and home-based exercise programs on older people with frailty or pre-frailty. METHODS: A total of 146 community-dwelling participants aged 65 and older who were prefrail or frail were randomly allocated into supervised exercise (N = 74) and home exercise (N = 72) groups. The 3-month supervised exercise training consisted of 3 exercise sessions per week, was performed at a hospital and supervised by a physical therapist. Home exercise participants took instructions on exercise and illustrated exercise handouts. The baseline and 3-month follow-up measurements included body composition, strength of selected upper and lower limb muscle groups, grip and leg press strengths, and five physical performance tests. Mixed-model repeated-measures analysis was applied to determine whether two groups differ in terms of changes before and after the intervention and to compare within-group improvements. RESULTS: After 3 months of supervised or home-based exercise, the average number of frailty criteria met and fat percentage decreased significantly. Strength of knee extensors, knee flexors and leg press improved significantly in supervised exercise group. In home-based exercise group, the strength of all muscle groups tested improved significantly, except for leg press strength. Walking speed improved in both groups, and timed-up-and-go and timed chair rise tests improved significantly only in supervised exercise group. CONCLUSIONS: Three-month supervised or home-based exercise improved walking speed and strength of the limb muscles. Supervised group showed more improvements in the physical performance tests compared with home-based exercise group.

Permanent central diabetes insipidus after mild traumatic brain injury.

AIM: The patients in the permanent diabetes insipidus (DI) group are more likely to have more severe TBI, which is defined by a post-resuscitational and pre-sedational Glasgow Coma Scale (GCS) score of 8/15 or less. This study presents a case of permanent, central DI following mild traumatic brain injury with post-resuscitation GCS 13/15. CASE REPORT: A 17-year-old boy suffered from mild brain injury and experienced permanent DI without any anatomical changes on image in the early stage of traumatic brain injury. However, 1 year later, magnetic resonance imaging (MRI) of the brain in this patient has revealed some sequel of contusion. Moreover, the patient still has DI after treatment with diamino-8-D-arginine vasopressin (DDAVP). CONCLUSION: This patient had a rare clinical presentation of permanent, central DI, following a mild traumatic brain injury. Identification of head trauma as the aetiology of hypopituitarism may be overlooked if there is a long delay in onset after trauma. Since anterior hypopituitarism can develop decades after the episode of head trauma, monitoring for endocrine dysfunction during follow-up of these patients is important.

Model-based prediction of length of stay for rehabilitating stroke patients.

BACKGROUND/PURPOSE: Accurate length-of-stay (LOS) estimates have an impact on medical costs for stroke patients. Most studies have reported only descriptive sample means or have provided linear-model-based estimates for LOS. This study calculated point and interval estimates by treating hospital discharge as an event, and utilizing the proportional hazards (PH) model to provide the estimation of hospital stay for first-ever stroke patients in a rehabilitation department of a clinical center. METHODS: Pairwise analysis for correlations between age, sex, comorbidity status, modified Barthel index (MBI) and functional independence measure (FIM) was performed. These explanatory variables are used in the K-sample comparisons, the Chi-squared test for association, the PH regression analysis, and log-transformed linear (LTL) regression. RESULTS: The PH model gave a prediction on estimated mean LOS, with an absolute bias of 0.85 days, by combining MBI and FIM into a single variable, or a bias of 1.15 days and 1.16 days with MBI and FIM variables, respectively. The LTL-based estimation generated a bias of 5.91 days. The PH model has relatively shorter confidence intervals than those obtained by sample-mean and LTL methods. CONCLUSION: We recommend using the PH model for predicting mean LOS when the PH assumption for patients with different clinical characteristics is satisfied. However, the proposed method only applies to rehabilitating stroke patients.

Wernicke encephalopathy concurrent with polyradiculoneuropathy in a young man after bariatric surgery: A case report.

RATIONALE: Bariatric surgery is the recommended treatment for morbid obesity because of its rapid and sustained body weight loss effect. Nutrient deficiency-related neurological complications after bariatric surgery are often disabling. Thus, early recognition of these complications is important. Neurological complications involving the central and peripheral nerve system after bariatric surgery were reported. However, the report on the clinical course of the concurrent involvement of central and peripheral nervous system is limited. We present a rare case of a patient who developed Wernicke encephalopathy concurrent with polyradiculoneuropathy after receiving bariatric surgery. PATIENT CONCERNS: A 22-year-old man with a history of morbid obesity presented progressive bilateral lower limbs weakness, blurred vision, and gait disturbance 2 months after receiving laparoscopic sleeve gastrectomy. Bilateral lower limb numbness and cognition impairment were also noted. DIAGNOSIS: Brain magnetic resonance imaging and electrophysiologic studies confirmed the diagnosis of Wernicke encephalopathy concurrent with acute polyradiculoneuropathy. INTERVENTIONS: Vitamin B and folic acid were given since admission. He also received regular intensive rehabilitation program. OUTCOMES: The subject's cognitive impairment and diplopia improved 1 week after admission under medical treatments, yet lower limb weakness and gait disturbance were still noted. After a month of intensive inpatient rehabilitation, he was able to ambulate with a walker for 30 munder supervision. LESSONS: Nutrient deficiency-related neurological complications after bariatric surgery are often disabling and even fatal. Prevention of neurological complications can be improved through close postsurgical follow-up of the nutritional status. Recognizing the signs and symptoms and evaluating the medical history are critical to the early diagnosis and treatment of this potentially serious yet treatable condition.

Gene-physical activity interactions in lower extremity performance: inflammatory genes CRP, TNF-α, and LTA in community-dwelling elders.

We assessed gene-gene and gene-physical activity interactions of polymorphisms in C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), and lymphotoxin α (LTA) genes on lower extremity performance in community-dwelling elders in Taiwan. Five SNPs (rs1205, rs1130864, rs1800947, rs2794520, and rs3093059) of CRP gene, three SNPs (rs909253, rs1041981, and rs2239704) of LTA gene, and three SNPs (rs3093662, rs1800629, and rs1799964) of TNF-α gene of 472 unrelated elders were genotyped. Lower extremity performance included timed up-and-go test (TUG), walking speed, weight-adjusted leg press (waLP), and timed chair stand (TCS). We detected significant interactions between physical activity with CRP rs2794520, rs1205, and rs3093059; LTA rs909253 and rs1041981; and TNF-α rs1799964 for TCS in women after covariate adjustment (all P < 0.05). In men, significant interactions between physical activity with CRP rs2794520, rs1205, and rs3093059; and LTA rs909253 and rs1041981 for TUG; with CRP rs2794520, rs1205, rs1130864, and rs3093059; and LTA rs909253 and rs1041981 for walking speed; and with TNF-α rs3093662 for waLP after covariate adjustment (all P < 0.05). These variants also significantly interacted with physical activity on TCS in women and on walking speed in men. These results show inflammatory genes are involved in lower extremity performance, likely via gene-physical activity interactions.

Effects of wrist position and contraction on wrist flexors H-reflex, and its functional implications.

In order to determine whether joint position exerts a powerful influence on length-tension regulation in multiarticulate wrist flexors, three wrist positions (neutral, flexion and extension) and four levels of flexor contraction [0%, 10%, 20% and 30% maximum voluntary contraction (MVC)] were manipulated. There were significant differences in H-reflex amplitudes according to wrist positions and levels of flexor contraction. H-reflex increased linearly as a function of contraction in all three wrist positions. H-reflex was consistently larger in the wrist flexion than in the wrist extension position. The strength of the relationship (omega2) indicated that wrist position had a greater effect on H-reflex than force of muscle contraction. The interaction between wrist flexors contraction and joint position was significant only in the wrist flexion position. Trend analysis showed that, in the wrist flexion position, a low level of contraction was sufficient to maximally facilitate the H-reflex; however, a quadratic component was seen at higher contraction levels. The above findings may reflect the length-tension relationship of the multiarticulate wrist flexors. Therefore, this paper will discuss the functional implications related to the larger H-reflex in flexion position and the depressed H-reflex in the wrist extension position.