Wernicke encephalopathy after bariatric surgery: Losing more than just weight D. Foster, DO; M. Falah, MD; N. Kadom, MD; and R. Mandler, MD Bariatric surgery is a frequent treatment for obesity. Neurologic complications after surgery include encephalopathy, behavioral abnormalities, seizures, cranial nerve palsies, ataxia, plexopathy, myelopathy, polyneuropathy, mononeuropathy (carpal tunnel syndrome, meralgia paresthetica), compartment syndrome, neuropathy, and myopathy. In particular, Wernicke encephalopathy, caused by vitamin B1 deficiency, can result in permanent neurologic deficit. 1,2 We report unusual clinical and imaging findings in a postgastric bypass patient with Wernicke encephalopathy.Case report. A 35-year-old woman underwent gastric bypass surgery for obesity. Subsequently, she reported anorexia, nausea, vomiting, and generalized fatigue, resulting in hospitalization. The patient continued to develop progressive hearing loss, psychomotor slowing, apathy, forgetfulness, ataxia, and bilateral hand paresthesias. In the 12th postoperative week, she had lost 40 lbs, was lethargic and confused, and had difficulty walking. She was awake but not attentive, speech was fluent, and comprehension was decreased. Pupils were equal and reactive to light, extraocular movements were intact, there was no nystagmus, and hearing was diminished. Strength was 3/5 in the lower extremities and normal in upper extremities, vibratory sense was diminished in feet, deep tendon reflexes were absent, plantar reflexes were down-going, and gait was wide-based. Laboratory tests were normal for blood count, thyroid function, vitamin B 12 , and CSF. Abnormal results included a slight elevation in liver enzymes, high serum glucose (163 mg/dL), and low serum potassium (2.6 MEq/L). EEG and head CT were normal.The patient's mental status continued to decline despite treatment for dehydration. Upon admission to our hospital, the heart rate was 125 beats/min; she opened her eyes to nail bed pressure but followed no commands and was nonverbal. The pupils were round and fixed at 3 mm, oculocephalic and deep tendon reflexes were absent, plantar reflexes were down-going, and general muscle tone was flaccid without spontaneous movements or withdrawal to painful stimuli. Abnormal test results were as follows: serum glucose (256 mg/dL), CSF protein (90 mg/dL), and diffuse slowing on EEG. Pretreatment red blood cell transketolase and serum thiamine levels were not down. The first MRI showed bilateral symmetric hyperintense signal on T2-weighted and fluidattenuated inversion recovery (FLAIR) images at the floor of the fourth ventricle, periaqueductal gray matter, the medial portions of both thalami, and the premotor and motor cortices (figure, A through C). All T2 hyperintense regions demonstrated contrast enhancement. Restricted diffusion was seen in the same regions on diffusionweighted imaging (DWI) and apparent diffusion coefficient maps.Initially, thiamine 100 mg IV showed no clinical improvement. Subsequently, high-dose thiamine (100 mg ...

IN BRIEF Rates of obesity and diabetes are growing, as are their costs. Because the two diseases share many key determinants, the paradigms for their treatment overlap. For both, optimal treatment involves a multidisciplinary team following the Chronic Care Model of health care delivery. Combined treatment programs that include 1) a low-calorie diet individualized to patients’ preferences, 2) structured exercise that is also tailored to each patient, and 3) psychotherapy induce the largest weight changes in patients with diabetes. Although diet alone can achieve weight loss, exercise and cognitive behavioral therapy components can enhance the effects of dietary modification. A multidisciplinary team that includes a physician with expertise in pharmacotherapy, a nurse and/or nurse practitioner, a dietitian, an exercise physiologist, and a psychologist can provide a comprehensive weight loss program combining the most effective interventions from each discipline.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. Given the lack of educational interventions for urban youth, our research team created a youth-informed, culturally relevant educational video on bike helmet safety, which was informed by focus groups with Baltimore City youth. This video, You Make the Call, linked the concept of use of cases to protect phones to use of helmets to protect heads and can be viewed at http://bit.ly/2Kr7UCN . The impact of the video as part of an intervention (coupled with a free helmet, fit instructions, and a parent guidance document) was tested with 20 parent–child dyads. The majority (80%) of youth (mean age 9.9 ± 1.8 years) reported not owning or wearing a helmet. At 1-month follow-up (n = 12, 60% response rate), helmet use was higher in the five youth reporting bike-riding after the intervention; 100% “always” used helmets compared to 0% preintervention. There were increases in youth reporting that parents required helmet use (35% pre vs. 67% post) and that is was possible to fall when bike-riding (60% pre vs. 92% post). These pilot results support the use of this video and educational intervention along with further evaluation in a larger sample size. This youth-informed and culturally tailored approach could be explored as a strategy to address other pediatric injury topics.

This article offers a critical assessment of empirical knowledge regarding labour market training and skills development in an era of technological disruption. Although exactly which skills and jobs will become obsolete is not known, technological change may cause unemployment to spike and increase the need for retraining. To move toward understanding what policy interventions will be needed in response, in this article we assess the current state of knowledge about Canada’s active labour market policies. We argue that before creating new programs, policy-makers need to learn from existing policy attempts to address labour market disruptions. By analyzing the most recent Employment and Social Development Canada evaluations, we find that quality data and analyses regarding the effectiveness of these programs are lacking. We conclude that research in this area is needed before policy-makers will be able to develop responses to technological disruption.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. We recruited eleven 8- to 15-year-old youth to participate in focus groups to inform the creation of a video promoting helmet use. Key emerging themes included that youth were responsible for keeping themselves safe and that most youth had cell phones with cases to protect them. A video was created that linked the concept of use of cases to protect phones to use of helmets to protect heads. Soliciting information from urban youth was helpful for developing this educational video.