Tumor necrosis factor receptor-associated factor 3 (TRAF3) is an anti-inflammatory molecule that negatively regulates the non-canonical nuclear factor-κB pathway. Although TRAF3 haploinsufficiency (TRAF3 HI) can influence innate and adaptive immune cells, its effect on inflammatory bowel disease (IBD) development remains unclear. Here, we report the first case of severe early-onset IBD with a novel TRAF3 variant leading to HI, successfully treated with ustekinumab. A 6-year-old girl with a recurrent parotitis, otitis media, tonsilitis, and atopic dermatitis developed IBD involving the stomach, small intestine, and colon. At diagnosis, the immunoglobulin (Ig)G and IgA levels were relatively high, and lymphocyte subsets showed increased counts of plasmablasts, class-switch recombination B cells, and circulating T-follicular helper cells. Treatment with azathioprine and infliximab failed to maintain remission marked by several relapses accompanied by erythema nodosum and arthritis; however, ustekinumab, an anti-interleukin (IL)-12/23p40 antibody, led to long-term clinical remission, normalizing the Ig level and reducing abnormal lymphocyte counts. Whole-exome sequencing revealed a novel heterozygous mutation in TRAF3 [p.(Pro487Leufs*8)], resulting in TRAF3 under-expression. Our case may highlight the contribution of TRAF3 HI to the development of IBD and provide insights into IBD pathophysiology, suggesting the involvement of the IL-12/23-T-follicular helper cell pathway affected by genetic mutations.

We present a successful case of a patient with multiple metal allergy—cobalt, nickel, chromium, and zinc—who had a past history of systemic metal dermatitis. He was a 58-year-old man who complained of exertional chest discomfort. After admission, he had a fever and his blood culture was positive with methicillin-sensitive Staphylococcus aureus. Three days later, multiple micro cerebral infraction was detected in magnetic resonance imaging. After an improvement of inflammatory reaction, he was transferred to our facility for cardiac examination. Moderate mitral regurgitation due to valve perforation and multiple coronary vessel stenosis were detected. Mitral valve replacement and coronary artery bypass grafting were planned to perform. We chose surgical materials based on a preoperative epicutaneous (patch) test and his clinical course was uneventful without any allergic reaction. Metal contact allergy is an important issue in cardiovascular surgery. A collaboration with dermatologists is essential for the preparation of surgical materials.

A 67-year-old man with dilated cardiomyopathy was admitted to our hospital for treatment of cardiac failure. After using heparin because cerebral infarction developed during hospitalization, in acknowledgment of thrombocytopenia, we reach the diagnosis of HIT. We judged surgery to be necessary because heart failure had difficulty with catecholamine secession and the left ventricular dilation progressed rapidly, and performed left ventriculoplasty, mitral valve plasty. There were no complications such as the thrombosis during cardiopulmonary bypass, and the postoperative course was good without leading to re-thoracotomy due to bleeding. He passes without a heart failure symptom by the follow of one year 6 months after surgery at home.

To evaluate the association of serum BDNF concentration with high-intensity interval training, 12 healthy male volunteers, aged 28-48 years, completed 16-week high-intensity interval training (HIIT) using ergometer. Training program consisted of >90% VO₂ peak for 60 sec separated by 60 sec active rest period for 8-12 sets twice weekly for 16-week. Maximal exercise tolerance tests were performed before (0-week), 4-week, and 16-week after the intervention program. VO₂ peak as well as peak watt was linearly increased after 4-week (9% for both VO₂ peak and peak watt) and 16-week HIIT training (15% for VO₂ peak and 18% for peak watt, p<0.01). However, there was no change in serum BDNF concentration by HIIT. On the other hand, there was a positive association of serum BDNF concentration at baseline with % increase in peak watt after the intervention (ρ=0.60, p<0.05). The association between BDNF and exercise training is still unclear, and more studies are needed to clarify the above positive association.

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.

Objectives: Spasticity is defined as a pathological increase in muscle tonus, and increased muscle tonus of lower limbs is a major obstacle to the stroke rehabilitation. Foot baths are considered to provide beneficial thermal therapy for post-stroke patients with spasticity, but their anti-spastic effects have not been investigated comprehensively. The present study aimed to evaluate alterations in spasticity and motor function using foot baths in post-stroke patients with spastic hemiplegia. Methods: We underwent two separate experiments each consisting of immersion in warm water up to the knee joint level, and measuring spasticity, physiological examination and motor function. Experiment 1; Fourteen post-stroke patients with lower limb spasticity were enrolled in this study (nine males and five females; mean age 50.4±12.9 years; range, 28-65 years). The subjects’ legs from below the knee joint were immersed in water at 41°C for 15 min. Measurements of F-waves and a physiological examination were carried out immediately (within 5 min) after the foot-bath session, and again 30 min later, while the subject remained wrapped in blankets on the lift-bath stretcher. Experiment 2; Six post-stroke patients with lower limb spasticity were enrolled in this study (five males and one female; mean age 55.2±14.6 years; range, 39-68 years). The subjects’ legs from below the knee joint were immersed in the artificial high concentration carbon-dioxide (CO2) water or tap water foot bath at 38°C for 30 min. Measurements of muscle stiffness, motor function (active range of motion: A-ROM) and a physiological examination were carried out immediately (within 5 min) after the foot-bath session, and again 10 min later, while the subject remained wrapped in blankets. Results: None of the subjects experienced discomfort before, during or after the foot-bath treatment. The physiological examination was completed safely in all subjects. Experiment 1; The mean values of F-wave parameters were significantly reduced after foot-bath treatment (P<0.01). The anti-spastic effects of foot-bath treatment were indicated by decreased F-wave parameters, in parallel with decreases in modified Ashworth scale (MAS) score. The body temperature was significantly increased both immediately after, and 30 min following foot-bath treatment. Experiment 2; The changes both in the body and surface skin temperature were higher in the artificial high concentration CO2 water foot bath compared with the tap water foot bath. The changes in the MAS score, muscle stiffness and A-ROM were also higher in the high concentration CO2 water foot bath than in the tap water foot bath. Conclusion: These findings demonstrate that the use of foot baths is an effective non-pharmacological anti-spastic treatment that might facilitate stroke rehabilitation. In addition, the high concentration CO2 water foot baths appeared to play an important role in decreased spasticity.

Objectives: The purpose of this study was to investigate whether the whole body vibration (WBV) inhibits spasticity and improves motor function and walking ability in the hemiplegic legs of post-stroke patients. Patients and Methods: This before-and-after intervention trial examined 13 post-stroke patients (11 male and 2 female; mean age, 54.3 ± 13.0 years; range, 24-72 years). The Brunnstrom Recovery Stage of the hemiplegic lower limb was stage 3 in three patients, stage 4 in 7, stage 5 in three. The modified Ashworth scale (MAS) score for the gastrocnemius muscles was 1 in one case, 1+ in 6 cases and 2 in six cases. All patients had increased muscle tonus of the affected lower limb (MAS score ≥1), and were able to walk without assistance using a T-cane or an ankle-foot orthosis. Exclusion criteria were any medical condition preventing vibratory stimulation (such as uncontrolled cardiopulmonary disease, severe joint disability and severe sensory disturbance), severe aphasia that made it impossible to follow verbal instructions, and dementia that interfered with outcome assessments. Each subjects sat on the chair with hip joint angles to approximately 90° of flexion, and with knee joint angles to 0° of extension. WBV was applied at 30 Hz (4-8 mm amplitude) for 5 min on hamstrings, gastrocnemius and soleus muscles (Figure 1). The parameters measured before and after the intervention were the MAS, the F-wave parameters as a measure of motor-neuron excitability, the active and passive range of motion (A-ROM, P-ROM) as a measure of motor function, and the 10-m walk test as a measure of walking ability. Results: None of the subjects experienced discomfort before, during or after the intervention and all assessments were completed safely in all subjects. The MAS and F-wave parameters were significantly decreased (p < 0.05), the A-ROM and P-ROM for ankle dorsiflexion increased (p < 0.01), and the P-ROM for straight leg raising increased (p < 0.01), and walking speed improved (p < 0.01) after the 5-min intervention. Conclusion: These findings suggest that WBV is an effective method for controlling spasticity, and improves motor function and walking ability in post-stroke patients.

Objectives: The warm-water foot bathing is widely used as a clinical method for hemiplegic limb. Recent research have reported that the artificial high concentration carbon-dioxide (CO2) water foot bathing have a potent vasodilative action. However, the definite effects of the artificial high concentration CO2 water foot bath for hemiplegic limbs remain uncertain. We examined that the effects of the artificial high concentration CO2 water foot bath for patients after stroke. Patients: Three inpatients after stroke were recruited for this study. The age and duration after onset were 58.3 ± 21.4 years and 63.0 ± 38.9 months, respectively. Of the three patients (two males and one female), two were diagnosed with cerebral hemorrhage, one with cerebral infarction. Methods: The artificial high concentration CO2 water foot bath and tap water foot bath were prepared. The concentration of CO2 water foot bath was approximately 1000-1,200 ppm, and both lower limbs (under the knee joint) were immersed in 38 °C water for 20 minutes. Foot bathing in tap water was also carried out under the same conditions in the another day. The following physiological data were measured before foot bathing and after the end of foot bathing. Not only the deep body temperature at axillary, the surface skin temperature at the front of femur, the calf of the leg and the dorsal foot, but also the muscle stiffness at triceps muscle of calf were evaluated. Results: None of the subjects experienced discomfort before and after both the high concentration CO2 water and the tap water foot bath. The physiological examination was completed safely in all subjects. The results were as follows: The deep body temperature and the surface skin temperature had increased, and the muscle stiffness had been relieved in the high concentration CO2 water foot bath compared with the tap water bathing. The deep body temperature of the high concentration CO2 water foot bath have risen from 36.4 °C to 36.9 °C, the surface-skin temperature of the front of femur (from 26.7 °C to 28.1 °C), the calf of the leg (from 29.5 °C to 31.9 °C) and the dorsal foot (from 29.9 °C to 32.3 °C) have risen, respectively. The muscle stiffness have been relieved from 55.3 to 51.8 before and after. There was no change that the tap water had increased in the deep body temperature and the surface-skin temperature, and the muscle stiffness had been relieved before and after. Conclusion: These results suggested that the use of the high concentration CO2 water foot bath was more effective in hyperthermia compared with the tap water. Furthermore, we considered that carbon dioxide had promoted to increase the skin and the muscle blood flow by vasodilative action to the arteriole, and use of the high concentration CO2 water foot bath contribute to improve the circulatory dynamics for the hemiplegic limb. These findings may suggest that the use of the high concentration CO2 water foot bath is an effective physiotherapy for circulatory dynamics treatment that might facilitate stroke rehabilitation