In recent years, our understanding of motor learning, neuroplasticity and functional recovery after the occurrence of brain lesion has grown significantly. Novel findings in basic neuroscience have provided an impetus for research in motor rehabilitation. The brain reveals a spectrum of intrinsic capacities to react as a highly dynamic system which can change the properties of its neural circuits. This brain plasticity can lead to an extreme degree of spontaneous recovery and rehabilitative training may modify and boost the neuronal plasticity processes. Animal studies have extended these findings, providing insight into a broad range of underlying molecular and physiological events. Neuroimaging studies in human patients have provided observations at the systems level that often parallel findings in animals. In general, the best recoveries are associated with the greatest return toward the normal state of brain functional organization. Reorganization of surviving central nervous system elements supports behavioral recovery, for example, through changes in interhemispheric lateralization, activity of association cortices linked to injured zones, and organization of cortical representational maps. Evidence from animal models suggests that both motor learning and cortical stimulation alter intracortical inhibitory circuits and can facilitate long-term potentiation and cortical remodeling. Current researches on the physiology and use of cortical stimulation animal models and in humans with stroke related hemiplegia are reviewed in this article. In particular, electromyography (EMG) -controlled electrical muscle stimulation improves the motor function of the hemiparetic arm and hand. A multi-channel near-infrared spectroscopy (NIRS) studies in which the hemoglobin levels in the brain were non-invasively and dynamically measured during functional activity found that the cerebral blood flow in the injured sensory-motor cortex area is greatest during an EMG-controlled FES session. Only a few idea is, however, known for the optimal timing of the different processes and therapeutic interventions and for their interactions in detail. Finding optimal rehabilitation paradigms requires an optimal organization of the internal processes of neural plasticity and the therapeutic interventions in accordance with defined plastic time windows. In this review the mechanisms of spontaneous plasticity after stroke and experimental interventions to enhance plasticity are summarized, with an emphasis on functional electrical stimulation therapy.

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Background: Successful vascular anastomosis is essential for the survival of transferred free tissue. Arterial anastomosis is typically uncomplicated because the lumen is easily maintained and the vessel walls have elasticity. Venous anastomosis, however, is more time consuming because the vessel walls are thin and extensible. This article describes, reviews, and compares 3 currently used venous anastomosis techniques. Methods: From April 2012 through January 2014, free tissue transfer and supercharging pedicled tissue transfer were performed in 107 and 10 patients, respectively, at our hospital. According to the anastomotic technique used, patients (83 men and 34 women; mean age, 60.6 years) were divided into interrupted suture, continuous suture, and microvascular anastomotic coupling device (MACD) groups. Medical records were reviewed, and postoperative results were analyzed. Results: The diameter of anastomosed veins did not differ significantly among the groups. However, among the interrupted suture, continuous suture, and MACD groups, there were significant differences in vascular anastomosis time (51, 43.9, and 29.5 minutes, respectively) and transferred tissue ischemic time (151.9, 139.1, and 117.5 minutes, respectively). Surgical site infection occurred in 9 patients, and flap necrosis occurred in 2 patients. However, complication rates did not differ significantly among the 3 groups. Conclusions: The venous anastomosis technique does not affect the complication rate but does affect anastomosis time and flap ischemia time. On the basis of these results, we believe that the continuous suture and MACD techniques are easier and safer for venous anastomosis than is the traditional interrupted suture technique.

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Background: Sustained erythropoiesis-stimulating agents (ESAs) have recently been identified as the standard therapeutic agent for anemia in patients undergoing peritoneal dialysis (PD). However, few reports have compared pain between various types of sustained ESAs or between administration routes. Furthermore, the change ratio of the dose of sustained ESAs reportedly ranges from 0.8 to 1.3. In the present study, to compare darbepoetin alfa and epoetin beta pegol (a continuous erythropoietin receptor activator [CERA]), we examined the dolorific differences between administration routes and the effect on anemia by using a chjange ratio of 0.8 with darbepoetin alfa in patients with renal anemia undergoing PD. Subjects and Method: We randomly assigned 20 patients with stable hemoglobin levels undergoing PD to either a darbepoetin alfa therapy group or a CERA therapy group. Based on a previous report, the change ratio of the CERA group from CERA to darbepoetin alfa therapy was assumed to be 0.8, and therapy was crossed-over to darbepoetin alfa again 2 months later. The dolorific evaluation (pain measurement) used both a face scale and a visual analogue scale. We compared the agents as well as administration routes with respect to pain. We also measured variables related to anemia and iron metabolism. Results: The change ratio of the CERA group at the start of the study was 0.821. On resumption of darbepoetin alfa therapy 2 months later, the doses of darbepoetin alfa increased. The darbepoetin alfa group showed a stronger tendency for pain, although the difference was not significant. In contrast, subcutaneous administration in the CERA group showed significant pain just after injection. The CERA group, however, showed a significant decrease in hemoglobin levels after 2 months of treatment (p=0.0489). No significant change was found in the hematocrit or the reticulocyte count. There were no significant differences in iron metabolism, as shown by serum iron levels and total iron-binding capacity, in either group. However, serum ferritin levels showed a tendency to decrease in the darbepoetin alfa group. Conclusion: No significant difference in pain was found between darbepoetin alfa and CERA therapies, but a significant difference in pain was noted between administration routes, just after injection, in the CERA group. The results also suggest that a change ratio of 0.8 from darbepoetin alfa to CERA is low for managing anemia.

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Background: The associations of glomerular capillary and endothelial injury with the formation of necrotizing and crescentic lesions in cases of crescentic glomerulonephritis (GN) have not been evaluated in detail. Methods: Glomerular capillary and endothelial cell injury were assessed in renal biopsy specimens of crescentic GN, including those from patients with anti-neutrophil cytoplasmic autoantibodies (ANCA) -associated GN (n=45), anti-glomerular basement membrane (GBM) GN (n=7), lupus GN (n=21), and purpura GN (n=45) with light and electron microscopy and immunostaining for CD34. Results: In ANCA-associated GN, anti-GBM GN, lupus GN, and purpura GN, almost all active necrotizing glomerular lesions began as a loss of individual CD34-positive endothelial cells in glomerular capillaries, with or without leukocyte infiltration. Subsequently, necrotizing lesions developed and were characterized by an expansive loss of CD34-positive cells with fibrin exudation, GBM rupture, and cellular crescent formation. With electron microscopy, capillary destruction with fibrin exudation were evident in necrotizing and cellular crescentic lesions. During the progression to the chronic stage of crescentic GN, glomerular sclerosis developed with the disappearance of both CD34-positive glomerular capillaries and fibrocellular-to-fibrous crescents. In addition, the remaining glomerular lobes without crescents had marked collapsing tufts, a loss of endothelial cells, and the development of glomerular sclerosis. Conclusions: The loss of glomerular capillaries with endothelial cell injury is commonly associated with the formation of necrotizing and cellular crescentic lesions, regardless of the pathogeneses associated with different types of crescentic GN, such as pauci-immune type ANCA-associated GN, anti-GBM GN, and immune-complex type GN. In addition, impaired capillary regeneration and a loss of endothelial cells contribute to the development of glomerular sclerosis with fibrous crescents and glomerular collapse.

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Objective: We examined obstetric and fetal/neonatal outcomes in women with a history of recurrent miscarriage. Methods: We reviewed the obstetric records of all 5,829 nulliparous pregnant women who delivered at #8805;14 weeks' gestation from 2008 through 2013 at our perinatal center. Of these women, 74 had a history of recurrent miscarriage (1.3%). The control population consisted of 4,176 nulliparous women without a history of miscarriage. Demographic information and characteristics of labor were extracted from patient charts. Results: The rate of maternal age #8805;40 years (p<0.01) and the rate of in vitro fertilization use (p<0.01) were higher in women with recurrent miscarriage than in women without miscarriage. Eleven women with recurrent miscarriage (14.9%) were treated with low-dose aspirin with and without subcutaneous heparin. In addition, the rate of cesarean delivery was higher in women with recurrent miscarriage than in women without miscarriage (p=0.02). However, fetal/neonatal outcomes did not differ significantly between the populations. Conclusion: The pregnancy of women with a history of recurrent miscarriage is not associated with adverse outcomes at our perinatal center.

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We report on a 70-year-old man with severe respiratory failure caused by obesity hypoventilation syndrome due to abdominal adiposis. Obesity hypoventilation syndrome is a severe condition that is diagnosed when all of the following criteria are satisfied: body-mass index >30 kg/m²; apnea hypopnea index >30; PaCO₂ >45 mm Hg (in the daytime); and marked daytime somnolence. Abdominoplasty, which is generally used for abdominal laxness, striae, and rectus muscle diastases and for women in the postpartum period, was performed for this patient to facilitate ventilator weaning and produced a satisfactory result.

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Background: Single-incision laparoscopic surgery has gained increasing attention due to its potential to improve the benefits of laparoscopic surgery. However, the technique remains technically challenging for most surgeons. We developed a new technique utilizing a needle grasper held in the surgeon's left hand as an alternative to conventional single-incision laparoscopic cholecystectomy (SILC). Patients and Methods: From August 2011 through May 2013, 29 patients at Nippon Medical School Musashi Kosugi Hospital, with gallbladder stones or polyps underwent single-incision laparoscopic cholecystectomy (SILC) with an additional needle grasper that was held in the surgeon's left hand (SILCAN) and introduced in the right subcostal region without a trocar. We analyzed intraoperative and postoperative outcomes of 29 patients for whom SILCAN was performed and retrospectively compared these outcomes to those of 32 patients who underwent conventional 4-port laparoscopic cholecystectomy (CLC) from January 2011 through May 2013. Results: No differences in patient characteristics or intraoperative/postoperative outcomes were observed between the groups. None of the patients in either group required conversion to an open procedure or additional ports. In the SILCAN group, no patients had complications within the first 4 weeks after surgery, with the exception of 1 patient with severe chronic cholecystitis in whom bile duct stenosis developed due to inadvertent clipping of the common hepatic duct. The frequency of postoperative analgesic use was similar in both groups, although none of the patients in the SILCAN group received analgesics for pain from the small, inconspicuous wound in the right subcostal region. Conclusions: SILCAN is a safe and feasible alternative to SILC which does not compromise the qualities of CLC. It is less technically challenging, and postoperative pain and cosmesis are comparable to those of conventional SILC.

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Anterior cervical fixation with autologous bone transplantation-without the need for harvesting bone from other sites, such as the ilium-was developed by Williams and modified by Isu et al. In recent intervertebral fusion procedures, after harvesting the cuboid bone from vertebral bodies, a hydroxyapatite block is placed between two harvested vertebral bones in the same way as in the sandwich method for intervertebral fixation. According to previous studies, this procedure has the following disadvantages: (i) as the corrective force for cervical kyphosis is insufficient, it could not be adapted for patients with preoperative kyphosis; (ii) special devices, including a microsurgical saw, are required for harvesting vertebral bones. In our modified method, we used a conventional high-speed drill instead of a microsurgical saw. Nevertheless, the results show that the operated spine can be stabilized to a greater extent by decreasing the height of the grafted bone, and this might help in reducing postoperative kyphosis.

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Vitamin K deficiency is associated with malnutrition in some complications, such as hyperemesis gravidarum, active gastrointestinal diseases, and psychological disorders. Maternal vitamin K deficiency can cause fetal bleeding, in particular, fetal intracranial hemorrhage. Although fetal hemorrhage is uncommon, severe damage to the fetus may be inevitable. We describe a pregnant woman with vitamin K deficiency possibly due to hyperemesis gravidarum. The patient was treated for the deficiency, and no fetal or neonatal hemorrhagic diseases were manifested.

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In addition to being the main cause of glomerulonephritis in children, poststreptococcal glomerulonephritis (PSGN) has recently been shown in older patients, especially those with malignancy or diabetes mellitus. The pathogenesis of PSGN has been ascribed to activation of complement 3 (C3) of the alternative complement cascade which, along with immunoglobulin (Ig) G and IgM deposits, is observed in renal tissue. Our aim here is to discuss the probable causes of PSGN developing with isolated IgM deposition in a 52-year-old patient with essential thrombocytosis followed-up over the previous 3.5 years. These characteristics make our case the first to be reported in the literature.

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We present a man with refractory leg ulcers, bilateral varicosis of the lower extremities, and Buerger disease. Autoimmune work-up was negative. However, chromosome analysis showed Klinefelter syndrome (48 XXY). Ulcerative lesions of the lower extremities are a complication of Klinefelter syndrome. To date, the pathogenesis of ulcers in Klinefelter syndrome has not been clarified, but several factors, such as abnormalities of fibrinolysis and prothrombotic states, might be involved. Our present case emphasizes the importance of considering Klinefelter syndrome in the differential diagnosis of a male patient with nonhealing ulcers of the lower extremities.

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A 33-year-old man presented with a lateral medullary infarction, vertigo, and nausea. At the time of hospital admission, he had Wallenberg syndrome. Although initial magnetic resonance imaging showed no abnormalities, subsequent diffusion-weighted magnetic resonance imaging showed a high-intensity area in the right lateral medulla oblongata. The right vertebral artery was shown to be dilated on basi-parallel anatomical scanning but to be stenosed on magnetic resonance angiography (MRA). Cerebral angiography 7 days after onset showed the "pearl and string sign" in the right vertebral artery. Follow-up MRA showed gradual improvement of the stenosis in the right vertebral artery. Multiple neuroimaging studies, such as MRA, basi-parallel anatomical scanning, 3-dimensional computed tomographic angiography, and cerebral angiography, should be performed soon after onset in suspected cases of cerebral artery dissection. In addition, serial imaging examinations increase diagnostic accuracy, and the medical history and neurological examination are important.

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