Sarcopenia is age-associated loss of skeletal muscle mass and strength which develops slowly over decades and becomes a significant factor to disability among the elderly population. Although several mechanisms of sarcopenia have been proposed, they all seem to affect the balance between muscle protein synthesis and breakdown, resulting in the net muscle loss. In present article, the most recent findings regarding the role of nutritional intake on muscle protein metabolism in the elderly will be reviewed. Particular focus will be given to dietary protein requirement for elderly, acute anabolic response of amino acids and protein intake, age-associated changes in the response of muscle protein to a meal intake, and the role of insulin resistance of muscle protein metabolism among the elderly. Finally, possible benefits and risks of protein and amino acid supplements for the prevention and treatment of sarcopenia will also be reviewed.

A 67-year-old man was admitted with heart failure. He had a past history of closed chest trauma due to a traffic accident at the age of 24. He had been complaining of a gradual increase of fatigue since a few years after the accident and received medical treatment. At approximately 40 years of age, he underwent cardiac catheterization and was given a diagnosis of Ebstein malformation. However surgery was not recommended. An echocardiogram showed a laceration at the tricuspid valve, enlargement of the tricuspid valve annulus and severe tricuspid regurgitation. The displacement of tricuspid valve was not present. His case was complicated with severe liver dysfunction of Child-Pugh class B and Model for End-Stage Liver Disease score 15. We performed tricuspid valve replacement with a Mosaic 31 mm tissue valve. The patient required pleurodesis for refractory severe pleural effusion at 2-months and was discharged 6 months after the operation.

Cardiac surgery for very-low-birth-weight infants is rarely reported, especially for a triplet. We herein report the successful staged repair of a premature triplet accompanied with transposition of the great arteries. During pregnancy, the fetuses were diagnosed as dichorionic diamniotic triplets, and the mother entered a hospital for maternal protection and health care from 25 weeks' gestation. The triplets were delivered by Caesarean section at 33 weeks and 5 days of gestation because of intrauterine growth retardation. One of the infants, weighing 1,336 g, was diagnosed with transposition of the great arteries (type II). Since he was deemed unable to endure an intracardiac repair, he received balloon atrial septostomy on the 27th day of life and then bilateral pulmonary artery banding on the 29th day of life. However, further balloon atrial septostomy on day 69 and left pulmonary arterial de-banding on day 73 post-birth were needed because of the progression of hypoxia. He received prolonged intubation and inotropic support after temporary cardiopulmonary stability, and we ultimately decided to perform arterial switch operation on day 110, when he weighed 1,838 g. The patient showed a good recovery. In the field of pediatric cardiac surgery, we occasionally select staged strategies for patients who cannot undergo radical operations all at once because of their general condition or low body weight. However, there are no established guidelines concerning the timing of palliative or radical operations in low-birth-weight infants. At present, we select medical strategies ourselves, on a case-by-case basis. In the present case, although our medical strategy had to be adapted, we still obtained a good recovery for this triplet with extremely low birth weight. We herein report this case with some references from the literature.

Purpose : We examined the effect of therapeutic exercise on osteoarthritis (OA) of the knee. Objects and Method : We evaluated seven women with bilateral OA of the knees of over Grade I on the Kellgren and Lawrence scale. The patients were instructed in therapeutic exercise for both knees. The exercise was to tie a Thera-Band ^® around the leg just above both ankles in the 8 figure, and then, in a sitting position, extend one leg while simultaneously retracting the other, repeating alternatively every 5 seconds. One set consisted of repeating this motion 10 times, and 2 sets were performed per day. Before exercise, 1 month, and 3 months after exercise, we evaluated the effect of this therapy by the JOA score, isokinetic muscle strength of knee extensors and flexors, and surface EMG signals recorded from rectos femoris (RF), vastus medialis (VM), vastus lateralis (VL), and biceps lemons (BF) . The integrated signal, the root mean square (RMS), and the mean power frequency (MPF) parameters were extracted.
Result : The parameters of the JOA score, muscle strength of knee flexors, integrated EMG from RF, VM, VL, and RMS from VM, VL were significantly increased at 3 months after exercise. MPF from VM at 3 months after exercise decreased significantly.
Conclusion : We thought a proper balance of knee extensors and flexors are related to the improvement of symptoms of OA of the knee. The decrease of MPF might suggest the possibility of muscle fiber type change. It is also possible that pain reduction results from the improvement of balance between knee extensors and flexors as well as from the increase of knee joint stability. Therapeutic exercise with the Thera-Band R is extremely easy and is effective in promoting con-tinuous exercise.

Objective: The aim of this study was to identify the content and methods of ethics education for medical representatives as part of the continuing education program and to suggest a preferable supportive method of ethics education accordingly.
Method: A questionnaire was mailed to the medical representative education managers of all 214 companies, all members of the MR Education & Accreditation Center, Japan.  The questionnaire was carried out from 31st July 2009 to 25th August 2009, and data from this questionnaire survey was analyzed by simple and cross tables.
Results: Out of the 182 (response rate: 85.0%) who responded, we analyzed the 173 institutions for analysis as they responded as having the continuing education program.  In terms of education, “the fair competition code” was the most widely educated (82.6%).  Although “the fair competition code” required most time, “the ethics as a medical representative” was considered as the most important.  The simple kappa coefficient between actual educating item and important item was 0.29.  Answers were affected by whether he/she had experience as a medical representative.  As the method of ethics education, “lecture” style was most common (87.4% of respondents), “group work discussion” was considered the most effective (70.6%) for training a medical representative to think and learn by himself/herself.  The respondents of 82.2% referred to the continuing educations’ guidelines made by MR Education & Accreditation Center, and 81.0% respondents felt “training materials for lectures and/or discussions” necessary in the future.
Conclusion: The ethics education for medical representatives placed a disproportionate emphasis on the importance of “the fair competition code.” Dissociation was seen between the actual education and the education considered as important by the respondents.  Accordingly, there is a need for appropriate materials for training and for a more adequate curriculum, taking time and content of education into consideration, especially for contents which training ways aren’t built up.

Objective: Environmental deprivation, a type of childhood maltreatment, has been reported to constrain the cognitive developmental processes such as associative learning and implicit learning, which may lead to functional and morphological changes in the ventral pallidum (VP) and pessimism, a well-known cognitive feature of major depression. We examined whether neonatal isolation (NI) could influence the incidence of learned helplessness (LH) in a rat model mimicking the pessimism, and the number of vesicular glutamate transporter 2 (VGLUT2)-expressing VP cells and Penk-expressing VP cells. Methods: The number of escape failures from foot-shocks in the LH test was measured to examine stress-induced depression-like behavior in rats. The number of VGLUT2-expressing VP cells and Penk-expressing VP cells was measured by immunohistochemistry. Results: In NI rats compared with Sham rats, the incidence of LH in adulthood was increased and VGLUT2-expressing VP cells but not Penk-expressing VP cells in adulthood were decreased. VGLUT2-expressing VP cells were decreased only in the LH group of NI rats and significantly correlated with the escape latency in the LH test. Conclusion These findings suggest that the aberrant VP neuronal activity due to environmental deprivation early in life leads to pessimistic associative and implicit learning. Modulating VP neuronal activity could be a novel therapeutic and preventive strategy for the patients with this specific pathophysiology.

Apical ballooning cardiomyopathy (Takotsubo or ampulla cardiomyopathy) is a well-known transient and localized left ventricular (LV) dysfunction characterized by apical severe hypokinesis, typical electrocardiogram (ECG) changes of negative T, and a lack of organic lesions of the coronary arteries which could cause myocardial ischemia leading to segmental asynergy. Here we report on two cases of transient cardiomyopathy showing atypically localized asynergy, which is different from Takotsubo cardiomyopathy. Case 1 was diagnosed as atypical Takotsubo cardiomyopathy, and the current findings suggest case 2 was viral myocarditis. These cases suggest that there exist variant patterns of transient cardiomyopathy, and non-invasive and serial clinical evaluations are important for differential diagnosis in acute and atypical cardiomyopathy.
Cardiomyopathy ; Acute ; Cases ; Localized ; Atypical

Recently, the problem of the high incidence of throwing injuries in young people has been gaining attention. Identifying high-risk players before the onset of the throwing injury is important for prevention. One of the most widely used screening tests for sports-related injuries is the Functional Movement Screen (FMS), which assesses the quality of movement; however, its correlation with throwing injuries has not been established. The purpose of this study was to investigate the correlation between the FMS score and throwing injuries. The FMS was used during the medical check for two hundred and thirty junior high school baseball players. We allotted those who had experienced throwing injuries multiple times to the injury group and those who had never experienced throwing injury to the control group. We then calculated the FMS cutoff value using the receiver operating characteristic curve. In addition, we investigated differences in the incidence of throwing injury between above and below the cutoff value using chi-square test. The FMS cutoff score was 17. Players who scored ≤17 had a significantly higher incidence of throwing injuries than those who scored ≥18. Conclusion: We believe that FMS score is correlated to throwing injuries. In addition, the results suggest that throwing injuries might be prevented in junior high school baseball players who scored ≤17 on the FMS if they undergo training in the correct movement patterns.

Sources of research funding: We gratefully acknowledge the support of the 17th Congress of the Japanese Society for Emergency Medicine support of this program.
Ethical considerations: The program was conducted after receiving approval from the Institutional Animal Experiment Committee of the Jichi Medical University, and in accordance with the Institutional Regulation for Animal Experiments and Fundamental Guideline for Proper Conduction of Animal Experiment and Related Activities in Academic Research Institutions under the jurisdiction of the Ministry of Education, Culture, Sports, Science and Technology of Japan. It was approved on April 9th, 2014. The approval number is 14-225.
Disclosure of conflicts of interests: We gratefully acknowledge the contributions of personnel from Panasonic Corp. who enabled the interactive communication system.
Abstract
Introduction: Live surgery demonstrations have been widely used in surgical education. However, they cannot be used to demonstrate trauma surgery due to the emergency situation and lack of informed consent. The aim of this study was to conduct a live demonstration of trauma surgery with a porcine model to increase educational opportunities in trauma surgery.
Methods: Live demonstration was conducted at the Center for Development of Advanced Medical Technology (CDAMtec) , Jichi Medical University, Japan. An experienced trauma surgeon instructed three trainees during a live demonstration using pre-planned injuries in a porcine model. A six-point Likert Scale was used on a written survey to determine the value of the program to the viewers. Free-form written comments were also obtained from the participants. Live images of the surgical field were transmitted to a lecture room by a closed wireless LAN with interactive bidirectional audio capability.
Results: Eighty-three participants viewed this live demonstration and completed the questionnaire. Participants were highly satisfied with the live demonstration (mean survey scores: 4.6-5.1/6) , and gave very positive feedback concerning the educational value of this program. Nine free-form comments were submitted, which revealed that the participants felt they could acquire concrete skills for trauma surgery.
Discussion: Live demonstrations for trauma surgery using a porcine model are a feasible and effective educational tool to demonstrate technical procedures and non-technical skills, with possible added advantages regarding the ethical considerations of performing a live surgery demonstration.

Methods: A total of 24 patients with postsurgical chronic pain and/or numbness Numeric Rating Scale (NRS) scores of ≥4 were enrolled. All patients underwent spine or spinal cord surgery at Keio University Hospital and received daily administration of DLX for more than 3 months. The mean postoperative period before the first administration of DLX was 35.5±57.0 months. DLX was administered for more than 3 months at a dose of 20, 40, or 60 mg/day, and the degree of pain and numbness was evaluated using the NRS before administration and 3 months after administration. Effectiveness was defined as more than a 2-point decrease in the NRS score following administration. Results: In terms of the type of symptoms, 15 patients experienced only numbness, eight experienced both pain and numbness, and one experienced only pain. Of the 24 patients, 19 achieved effective relief with DLX. DLX was effective for all patients with postsurgical chronic pain (n=9), and it reduced postsurgical chronic numbness in 18 of 23 patients. No significant difference was observed in background spinal disorders. DLX was not effective for five patients who complained only of postsurgical chronic numbness. Conclusions This study reports the effectiveness of DLX for postsurgical chronic neuropathic disorders. Although DLX reduced postsurgical chronic pain (efficacy rate=100%) and numbness (78.3%) in certain patients, further investigation is needed to determine its optimal use.