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Background Remimazolam is a newly developed benzodiazepine with more rapid onset and offset of sedation effects than midazolam. We report elderly patients in whom a small dose of remimazolam was successfully used for general anesthesia. Case presentation Two elderly women (patients 1 and 2, aged 95 and 103 years, respectively) underwent hip fracture surgery under general anesthesia guided by bispectral index (BIS). Anesthesia was induced with 1.2 and 1.0 mg/kg/h and maintained with 0.2 and 0.1 mg/kg/h remimazolam, combined with fentanyl and remifentanil in patients 1 and 2, respectively. Their hemodynamics were stable with a small dose of vasopressor, and they awoke soon after the discontinuation of remimazolam without flumazenil reversal. Their postoperative courses were uneventful without any complications. Conversely, the remimazolam dose required to achieve adequate sedation were much lower than expected. Conclusion Remimazolam could be useful in general anesthesia, particularly for super-elderly patients. However, the appropriate dose for induction and maintenance of anesthesia should be carefully considered based on BIS or vital signs.

Although the association between cholecystitis and acute coronary syndrome-like symptoms, including chest pain with electrocardiogram (ECG) changes, has been reported previously, it is unclear whether these symptoms can be provoked by direct stimulation to the gallbladder. We present the case of a 44-year-old man who developed coronary artery spasm (CAS) with ST-segment-elevation followed by nonsustained polymorphic ventricular tachycardia during laparoscopic cholecystectomy. The change in ECG occurred only when the gallbladder was manipulated, suggesting that direct stimulation to the gallbladder can cause CAS. Clinicians should be aware that careful ECG monitoring is necessary, especially while the gallbladder is manipulated.

Purpose The Hybrid Assistive Limb® (HAL®, CYBERDYNE) is a wearable robot that provides assistance to a patient while they are walking, standing, and performing leg movements based on the wearer’s intended movement. The effect of robot-assisted training using HAL® for cerebral palsy (CP) is unknown. Therefore, we assessed the effect of robot-assisted training using HAL® on patients with CP, and compared walking and gross motor abilities between pre-intervention and post-intervention. Methods Six subjects with CP were included (mean age: 16.8 years; range: 13–24 years; Gross Motor Function Classification System levels II–IV: n = 1, 4, 1). Robot-assisted training using HAL® were performed 2–4 sessions per week, 20 min per session, within a 4 weeks period, 12 times in total. Outcome measures included gait speed, step length, cadence, single-leg support per gait cycle, hip and knee joint angle in stance, and swing phase per gait cycle, 6-minute walking distance (6 MD), physiological cost index (PCI), knee-extension strength, and Gross Motor Function Measure (GMFM). Results There were significant increases in self-selected walking speed (SWS), cadence during SWS and maximum walking speed (MWS), single-leg support per gait cycle, hip joint angle in the swing phase, 6 MD, and GMFM. In contrast, gait speed during MWS, step length during SWS and MWS, hip and knee joint angle in the stance phase, knee joint angle in the swing phase, PCI, and knee-extension strength generally improved, but not significantly. Conclusion Robot-assisted training using HAL® may improve walking and gross motor abilities of patients with CP.

Background: The motor functions of Rett syndrome patients degrade during the course of the disease. Some patients, however, are able to maintain their motor functions by undertaking exercise programs. Case: A 2-year-old girl was diagnosed with Rett syndrome after the identification of a mutation in the gene encoding the methyl-CpG-binding protein. The patient started weekly rehabilitation therapy; however, over time, this reduced to monthly sessions, and subsequently, because of worsening epileptic seizures, even fewer sessions were possible. When the patient was 12 years old, intensive rehabilitation therapy was undertaken for 1 month; therapy involved 80 min of in-hospital therapy on weekdays and walking exercises at home at the weekend. An accelerometer (Actiwatch 2, standard type, Philips Respironics) indicated that more than 60 min of daily training at an intensity of 3 metabolic equivalents (METs) or more was achieved at weekends. The patient took the 10-m walk test, and the average time reduced from 18.6 to 13.5 s and the number of steps reduced from 32 to 23 between the start and finish of the first 1-month intensive training regime. After being discharged from the hospital, the patient maintained walking exercises at school during weekdays and performed more than 50 min/day of activity at at least 3 METs at home on weekends, in addition to a weekly home-visit rehabilitation therapy and the annual in-hospital 1-month rehabilitation therapy. Four years later, the patent’s average time and number of steps required to walk 10 m remained lower (12.7 s, 24 steps) than those recorded at the first evaluation. Discussion: Periodic rehabilitation therapy and proactive walking exercises at more than 3 METs for a duration of up to 50 min/day were instrumental in maintaining the motor functions of a Rett syndrome patient.

Middle interhemispheric variant of holoprosencephaly (MIH) is a rare brain malformation; hemispheric fusion does not occur at the rostral forebrain, but rather across the posterior frontal region. Barkovich and Quint1 first described and proposed MIH as part of the holoprosencephaly (HPE) spectrum in 1993. Although classic HPE and MIH share several similarities, they are related to different embryological mechanisms: classic HPE is caused by a defect in the formation of the embryonic floor plate, whereas MIH occurs after a disturbance to the roof plate formation.2 The gene ZIC2 is important for the differentiation of the roof plate in the dorsal midline of the neural tube of the developing embryo. In humans, ZIC2 mutations have been identified in 3%–4% of HPE cases, including individuals with MIH, thus confirming that MIH is a variant of HPE.3

Growing evidence indicates that the endocannabinoid system is important for the acquisition and/or extinction of learning and memory. However, it is unclear which endocannabinoid(s) play(s) a crucial role in these cognitive functions, especially memory extinction. To elucidate the physiological role of 2-arachidonoylglycerol (2-AG), a major endocannabinoid, in behavioral and cognitive functions, we conducted a comprehensive behavioral test battery in knockout (KO) mice deficient in monoacylglycerol lipase (MGL), the major hydrolyzing enzyme of 2-AG. We found age-dependent increases in spontaneous physical activity (SPA) in MGL KO mice. Next, we tested the MGL KO mice using 5 hippocampus-dependent learning paradigms (i.e., Morris water maze (MWM), contextual fear conditioning, novel object recognition test, trace eyeblink conditioning, and water-finding test). In the MWM, MGL KO mice showed normal acquisition of reference memory, but exhibited significantly faster extinction of the learned behavior. Moreover, they showed faster memory acquisition on the reversal-learning task of the MWM. In contrast, in the contextual fear conditioning, MGL KO mice tended to show slower memory extinction. In the novel object recognition and water-finding tests, MGL KO mice exhibited enhanced memory acquisition. Trace eyeblink conditioning was not altered in MGL KO mice throughout the acquisition and extinction phases. These results indicate that 2-AG signaling is important for hippocampus-dependent learning and memory, but its contribution is highly task-dependent.