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Background Hip fractures are high risk and high-impact events in the elderly population; despite orthopedic hip surgery, the disability and mortality rate remains significant. The National Health Insurance Agency in Taiwan established a fragility fracture PAC rehabilitation program to provide functional recovery for these patients after the surgery. However, the current literature on PAC rehabilitation is outdated, and there is an urgent need for the re-evaluation of the program. Methods This is a retrospective cohort study that enrolled 159 patients in the PAC rehabilitation program, followed by hip repair surgery. Outcome measures were the differences in participants’ pre- and post-PAC scores in 1) Barthel index, 2) Numerical Rating Scale (NRS), and 3) Harris Hip Scores (HHS) as surrogate indicators of the functional status, followed by the analysis of subgroups, including sex, age, site of the fracture, type of procedure, and the number of comorbidities. Results After completing PAC rehabilitation, 86.2% of the patients successfully returned to the community with either home or out-patient rehabilitation. The re-admission rate was 3.1% and 3.8% in 14-days and in 30-days follow up, respectively. The difference in pre- and post-Barthel index, NRS, and HHS showed significant improvement (p<0.001), without significant variations between the subgroups. Additionally, the Barthel index showed a positive correlation to HHS and a negative correlation to NRS. Conclusion This study revealed that the current form of post-surgery fragility fracture PAC program effectively improves functional status, reduces the re-admission rate, and facilitates the patient transition back to the community. The results should improve patients’ and physicians’ confidence in such a program.

Rationale:Mitochondrial DNA mutations have been associated with many maternal inherited diseases. A1555G mutation in mtDNA effects the gene code for rRNA, resulting in the structural change of human ribosome rending it susceptible to binding of the common antibiotic, aminoglycosides. Such mutation has linked with non-syndromic hearing loss and is one of the most common mtDNA mutations in Asian populations.Patient concerns:A 50-year-old Taiwanese female visited our neurology department with concern for multiple members with hearing loss in her family, including herself.Diagnoses:Physical examination findings were not significant besides hearing loss and brain MRI did not reveal any lesions. BAEP confirmed bilateral peripheral sensory deficit. Given the multiple cases of hearing loss in the family, a genetic cause was suspected. Using PCR and sequences chromatogram technique we have identified A1555G mutation on her mtDNA affecting region codes for 12S rRNA. Additionally, we observed severe speech disorder in two young family members with the onset of hearing loss began in their early childhood.Interventions:The patient declined any form of intervention at the time for personal reasons.Outcomes:The patient was satisfied with the diagnosis, her and her families are continuously followed by our neurology department.Lessons:We report on a family with mtDNA mutation hearing loss that is related to exposure to aminoglycosides. Children with such mutation are at high risk for impaired linguistic function. Early identification and intervention with cochlear implant should be considered.

Background and purpose The implantation of carotid artery stents prevents recurrent ischemic stroke in patients with carotid stenosis. This study aimed to investigate associations between change of ophthalmic artery flow (COAF) post carotid stenting and recurrent ischemic stroke, as well as the link toward the anterior and posterior circulations and patients’ prognosis after carotid stenting. Methods This retrospective, longitudinal cohort study recruited 87 left side carotid stenosed ischemic stroke patients undergoing left side carotid stenting between year of 2009 and 2013, and patients were followed up to 9 years after carotid procedures. Clinical data were derived from medical records. The primary outcome was stroke recurrence. Predictive factors were stenosis  > 50% in one intracranial artery and ROAF. Kaplan–Meier and Cox regression analyses were used to identify risk factors associated with stroke recurrence. Results Among 87 included patients undergone left side carotid stent treatment, 44 had stroke recurrence within 3 years after carotid stenting. The recurrence group had significantly greater proportions of COAF after stenting (p = 0.001), and middle cerebral artery (MCA) and basilar artery or vertebral artery (BA/VA) stenosis > 50% (all p < 0.001) than the no-recurrence group. Survival was significantly shorter in patients with COAF than in those without (p < 0.01). Regression analysis showed that COAF was associated with stroke recurrence (HR: 3.638, 95% CI 1.54–8.62, p = 0.003). The recurrence rate was highest in patients with bilateral MCA stenosis  > 50% (100%), followed by left MCA stenosis  > 50% plus BA/VA stenosis  > 50% (83.33%) or COAF (82.14%). Patients with bilateral MCA stenosis  < 50% had no recurrence within 3-year follow-up. Conclusions Prognosis after carotid stenting is poorer for patients with MCA stenosis  > 50%, BA/VA stenosis  > 50% and/or COAF. Carotid duplex and magnetic resonance angiography provide definitive information for prognosis prediction.

Introduction Pembrolizumab and other immune checkpoint inhibitors are the emerging treatment for selected, high-grade malignancies. However, a small number of patients are unable to tolerate its adverse effects, leading to discontinuation of this potentially life-changing therapy. In this study, we present a case of high-grade urothelial carcinoma patient, who experienced neurocomplications during the first pembrolizumab administration. However, we were able to limit the adverse effect by concomitant use of low-dose oral steroids. Case presentation A 75-year-old Taiwanese female with high-grade urothelial carcinoma of the left ureter came to the neurology clinic with complaints of acute onset of bilateral ptosis 16 days after her first infusion of pembrolizumab. It was found that she developed complete bilateral ptosis and limited extraocular muscle movements. Myasthenia gravis-related antibodies and repetitive stimulation test were negative. We diagnosed her with pembrolizumab-induced myasthenia gravis-like disorder and myositis based on clinical symptoms and elevation of muscle enzymes. We commenced methylprednisolone pulse therapy followed by oral steroid therapy with gradual resolution of the symptoms. Three months later, the patient received a second cycle of pembrolizumab with low-dose oral steroids without any complications. Conclusion Pembrolizumab exerts its antitumor activity by interfering with the binding of programmed death 1 and its ligand, programmed death ligand 1. As a result, enhanced cytotoxic T cells can recognize tumor cells and induce cellular death. However, neurological complications may be severe and require prompt recognition and treatment. Our case demonstrated that concomitant use of low-dose steroids and pembrolizumab might prevent such complications.