A multicenter review of the medical records of Japanese post-stroke patients with spastic hemiplegia was conducted to investigate the clinical use of botulinum toxin type A (BoNT/A) by physicians with expertise in the treatment of upper and lower limb spasticity. An analysis of the data from 307 patients treated with BoNT/A during the period January 1, 2012 to November 30, 2013 provided a variety of information on factors relating to BoNT/A injection outcomes, including the total dose of BoNT/A per treatment session, the dose of BoNT/A per muscle, the number of injection sites per muscle, the method used to locate the muscles to be injected, and the dilution of reconstituted BoNT/A. Our analysis indicated that the dose of BoNT/A administered per muscle was usually selected by taking into consideration the severity of spasticity, rather than the patient's body size. Since the technical expertise of experienced clinicians is summarized in this data, it may serve as a useful reference for the use of BoNT/A in routine clinical practice.

In this paper we introduce recent developments in the studies of brain activation during somatosensory stimulationexploiting new technologies. Somatosensory stimulation such as acupuncture, inauces tocai activation in tne central nervous system. The electroencephalogram is a popular method to investigate this activation, however, it is difficult to identify the exact location of the activation site. Recent new technologies may provide more accurate localization. Besides magnetoencephalography (MEG), which recognizes the activated brain areas by an evoked magnetic field with induced current, two other methodologies, which take advantage of physiological phenomena occurring during brain activation, were used in this functional study. Following excitation of neurons, brain tissue is supplied with oxygen from oxyhemoglobin causing oxyhemoglobin to turn into deoxyhemoglobin. As a consequence deoxyhemoglobin increases in the brain tissue. In the near-infrared spectrum, the deoxyhemoglobin absorption peak shows higher signal intensity than that of oxyhemoglobin, for which reason activated brain areas can be identified by absorption maps. In functional magnetic resonance imaging (fMRI) activated area can be revealed with high spatial resolution due to the change in magnetic susceptibility of deoxygeneated blood. This paper describes fMRI studies employing these three methods for the evaluation of experiments using acupuncture for focal brain activation.

To develop a simple test of endurance capacity in the elderly, we evaluated the reliability and validity of the shuttle stamina walk test (SSTw), in which the running in the shuttle stamina test (SST : 3-minute shuttle running along a 10-meter course) was changed to walking.
We found that: 1) The walking distance in the SSTw was correlated with Vo₂max (r=0.827), 2) the walking distance showed a correlation between the first test and a re-test (r=0.853), 3) the mean peak heart rate during the test was 86.3% of the estimated maximum heart rate with no difference according to age or sex, 4) subjective evaluation of the intensity of exercise was expressed as“fairly light”or“somewhat hard”by 73.7% of the subjects, 5) the results of the SSTw reflected the subjects' self-evaluation of endurance capacity, and 6) the age-related percentage reduction of the walking distance in the SSTw was similar to that in V₂max in subjects aged 40 years and above.
These results suggest that the SSTw, a simple test of endurance capacity that can be performed safely over a wide range of middle-aged to elderly people including those in late old age and those with a low fitness level, has sufficient reliability and validity.

In the context of energetics related to a pendular model, the mechanical power (W) and ‘pendular motion efficiency’ (PME) were determined during walking of the subjects who consist of 37 healthy elderly women (65-85 years) and 21 young women (18-25 years) . Using a force plate, the potential and kinetic energies of the body's centre of mass were measured at various constant speeds. Walking speeds were selected and controlled by a newly devised pace-maker. PME, which is equivalent to ‘% recovery’ by Cavagna (1976), indicates a sort of efficiency in transforming potential energy into kinetic energy and vice versa. The external power to accelerate the body (Wext ), which is thought to be supplied by muscles, increased with walking speed, and the rate of increase in Wext tended to be greater in the elderly than in the young subjects. It was noted that the maximal PME values at the optimum speed in both age groups were comparable, but PME values in the elderly decreased more markedly than in the young subjects as walking speed deviated from the optimum. This fact suggests that an adaptability to different walking speeds reduced in the elderly population.

The factors that influence the risk of accidents during the replacement of gastrostomy catheters remain unknown and therefore have not yet been thoroughly investigated. We conducted a nationwide questionnaire survey of 415 rehabilitation-training facilities for the replacement of gastrostomy catheters. We received 221 valid responses. Among the catheter replacement methods submitted, the bumper button replacement method was the most widely chosen, comprising 40% of the valid responses. The measures used to prevent accidental erroneous catheterization included examination of the stomach contents, endoscopic examination of the stomach, and the detection of insufflation sounds, although these measures varied widely among the facilities. Fifty-one out of the 221 facilities that responded to the survey experienced various mishaps, of which 20 were due to erroneous catheterization. In approximately 40% of the facilities, there was no operative manual for the replacement nor was the patient's consent taken before performing the procedure. This investigation elucidates the risks involved in the replacement of gastrostomy catheters. This survey also suggests that the methods used for catheter replacement should be re-examined to prevent accidents during the replacement.

SUMMARY AND PERSPECTIVE We demonstrated two kinds of impairing effect of glucose overload on endothelial Ca2+ mobilization; i.e., 02- mediated and protein kinase C-mediated ones. As already mentioned in the previous sections, endothelium-dependent vasodilation was impaired in aorta by the hyperglycemia-induced production of 02- (Tesfamariam & Cohen, 1992). In contrast, vasodilation in response to agonists such as acetylcholine and histamine was impaired by hyperglycemic condition in cerebral microvessels by the production of protein kinase C (Mayhan & Patel, 1995). Our observations happened to support these reports; i.e.,02-was responsible for glucose overload-induced impairment of Ca2+ mobilization in aortic endothelium and protein kinase C in brain microvascular endotheluim. However, because each mechanism affects Ca2+ mobilization in a quite different mauler, we suppose that this does not simply imply the site-specificity of the impairing action of glycose overload, but is due to the difference of Ca2+ mobilization mechanism. In other words,02- mainly affects Ca2+ pathways such as channels and pumps, and protein kinase C affects the signaling cascade which is related to Ca2+ mobilization. As summarized above, many Ca2+ mobilizing pathways, which are regulated by various biochemical and biomechanical stimulation, are involved in the regulation of endothelial [Ca2+]i. However, the details of such Ca2+mobilizing mechanism are not fully clarified. For instance, it is not known whether the cyclic AMP-mediated Ca2+ release observed in brain microvascular endothelium plays a significant role also in other vessels such as aortic endothelium. Therefore, the detailed clarification of the mechanisms of Ca2+ mobilization in vascular endothelium has an essential importance in vascular biology not only for physiological reason but also for pathophysiological reason.
Acetylcholine ; Aorta ; Biology ; Brain ; Calcium* ; Endothelial Cells* ; Endothelium ; Endothelium, Vascular ; Glucose* ; Histamine ; Homeostasis* ; Microvessels ; Protein Kinase C ; Protein Kinases ; Vasodilation

Objective: The Hyogo Hospital Pharmaceutical Society has been conducting an original pharmacy postgraduate education program, “lifelong learning program (to nurture pharmacy specialists)”, since 2002 using the Internet.  To understand the status of using this program, this study employed a questionnaire survey involving all registered members.
Methods: Subjects were all members (1,870) of the society.  Questionnaires were distributed and collected by mail.
Results: Only 20.1% of the members had experience of using the program, and the frequency of using it was less than once per 6-12 months in 60% of the members.  Their level of awareness concerning the acquisition of credits for lifelong learning was 36.9%.  The program category they wished to take was an infection-related program in 26.1% of the members, which was the highest.
Conclusion: As reasons for only a small number of members using the program, the following are considered: loss of user’s ID and password required to login, and lack of awareness concerning the acquisition of credits for lifelong learning offered by the Japanese Society of Hospital Pharmacists.  As future issues, we must encourage members to obtain a new password and be proactively involved in preparing new program categories that the members wish to take, in order to promote the continuous use of the program.

The number of patients with diabetes mellitus (DM) in Japan is increasing. Progression of DM leads to the development of diabetic peripheral neuropathy, which causes foot sensory disturbances. This study examined the effect of DM on plantar tactile point pressure sensitivity (TPPS) and identified the site with the highest threshold of plantar TPPS. The subjects were 42 DM patients (aged 71.7±8.2 years) and 122 local elderly residents (aged 72.6±4.8 years). TPPS of eight sites, including the right and left halluces, hallux and fifth toe metatarsal heads, and heels was measured using the Semmes-Weinstein monofilament test. The measurement was performed three times at each site. The results were adopted when all repeated measurements were valid. The Friedman test was used for comparison among the four sites within the same group. The Mann-Whitney U test was used for comparison of sites between groups. A significance level of 5% was adopted. The ages of the DM patients were not significantly different, but the patients had significantly higher TPPS threshold for halluces, and hallux and fifth toe metatarsal heads, compared to the local elderly residents. The TPPS threshold was highest in the heels in both the DM patients and local elderly residents. The threshold of plantar TPPS increases in DM. It is important to evaluate both the forefoot and the heels.

Objective : To evaluate the efficacy and safety of botulinum toxin type A (BTXA) in Japanese patients with post-stroke lower limb spasticity in a multicenter, randomized, double-blind, single dose, placebo-controlled study (double-blind phase) followed by an open-label, multiple dose extension (open-label phase). Methods : One hundred and twenty patients with lower limb spasticity were randomized to receive a single treatment with BTXA 300 Units (U) or placebo into lower limb muscles in the double-blind phase. Patients who met the re-injection criteria received up to 3 repeated treatments of BTXA into lower limb muscles with at least 12 weeks between treatments in the open-label phase through 48 weeks. Results : In the double-blind phase there was significant improvement from baseline spasticity in the Modified Ashworth Scale (MAS) ankle score between the BTXA 300U and placebo groups, with a mean difference in the area under the curve (AUC) of -3.428 (p=0.006, t test). The MAS ankle score further decreased from baseline in all repeat treatment cycles of BTXA in the open-label phase. No clinically relevant difference was noted in the frequency of treatment-related adverse events between BTXA-treated and placebo-treated patients during the study period. Conclusions : BTXA reduced spasticity in lower limb muscles from the first treatment with continued long-term efficacy. BTXA is safe and effective for the long-term treatment of post-stroke lower limb spasticity.

Objective : To evaluate the efficacy and safety of botulinum toxin type A (BTXA) in Japanese patients with post-stroke upper limb spasticity in a multicenter, randomized, double-blind, single dose, placebo-controlled study (double-blind phase) followed by an open-label, multiple dose extension (open-label phase). Methods : One hundred and nine patients with upper limb spasticity were randomized to receive a single treatment with either a lower dose (120-150 Units ; U), higher dose (200-240U) BTXA or placebo into upper limb muscles in the double-blind phase. These treatments were administered to improve wrist and finger flexion for all patients and thumb flexion in patients with thumb spasticity. Patients who met the re-injection criteria received up to 3 repeated treatments of BTXA (200-240U) into their upper limb muscles with at least 12 weeks between treatments in the open-label phase through 48 weeks. Results : In the double-blind phase there was significant improvement from baseline spasticity on the Modified Ashworth Scale (MAS) wrist score between the higher dose BTXA and placebo groups, with a mean difference in the area under the curve (AUC) of -6.830 (p<0.001, t test). The MAS wrist score further decreased from baseline in all repeat treatment cycles of BTXA in the open-label phase. No clinically relevant difference was noted in the frequency of treatment-related adverse events between BTXA-treated and placebo-treated patients during the study period. Conclusions : BTXA injections reduced spasticity in the upper limb muscles from the first treatment with continued long-term efficacy. Our results suggest that BTXA injections are safe and effective for the long-term treatment of post-stroke upper limb spasticity.