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Infection is a serious potential complication after left ventricular assist device (LVAD) implantation. In general, infection of the device pocket, with device exposure, should be managed by early device removal and heart transplantation. However, because of the small number of donors in Japan, accelerating access to heart transplantation is often difficult and the LVAD can be widely exposed during the waiting period. We report our experience of successful heart transplantation in a patient with a widely exposed LVAD with pocket infection. A 48-year-old man suffered from heart failure due to idiopathic dilated cardiomyopathy. An LVAD was implanted, but postoperative infection led to blood pump exposure. Heart transplantation was performed 4 months after LVAD exposure, at which time the epigastric skin defect measured 14 × 8 cm. The skin defect could not be closed after heart transplantation, so it was covered by an omental flap with split-thickness skin grafts. 7 days postoperatively, the peritoneal suture broke and the intestinal tract prolapsed outside the body. Reintroduction of the prolapsed intestinal tract and deep inferior epigastric artery perforator (DIEP) flap coverage of the omental flap were performed. The postoperative course was uneventful. There have been no reports of the management of wide skin defects in the presence of infection when heart transplantation is performed. Omental flap placement was useful for controlling long-lasting infection. An omental flap placed in a patient with a wide epigastric skin defect should be covered by durable skin flap, such as a DIEP flap, to avoid intestinal prolapse.

Background: Facial edema is a common complication after neck dissection and/or chemoradiotherapy for head and neck cancer. Edema subsides spontaneously in most cases but sometimes persists, in which case surgical intervention is required. We report a case of severe facial edema that showed significant improvement upon lymphovenous anastomosis (LVA)., Methods: A 66-year-old man with oral floor cancer developed progressive facial lymphedema after tumor resection, bilateral neck dissections, chemoradiotherapy, and fibular and rectus abdominis musculocutaneous flap transfer. His eyesight was completely disturbed due to severe eyelid edema. The LVAs were performed in the bilateral preauricular area. Surgical findings showed stagnation of the lymphatic fluids in dilated lymphatic vessels, which were drained to the superficial temporal veins by LVA., Results: The edema subsided rapidly and the patient's eyesight returned as soon as 4 days postoperatively., Conclusion: Using LVA in the preauricular region can be a choice of surgical treatment for severe facial edema., (© 2018 Wiley Periodicals, Inc.)

Aim: This study investigated the relationship between the initial diuretic response to tolvaptan and clinical predictors for tolvaptan responders in patients with acute decompensated heart failure (ADHF)., Methods and Results: Patients (153) with ADHF (clinical scenario 2 or 3 with signs of fluid retention) who were administered tolvaptan were enrolled. Tolvaptan (15 or 7.5 mg) was administered for at least 7 days to those patients in whom fluid retention was observed even after standard treatment. The maximum urine volume immediately after tolvaptan administration showed good correlations with the ejection fraction and estimated glomerular filtration rate that were independent predictors of the urine volume (UV) responders (≥1500 mL increase in urine volume). The diuretic response (in terms of maximum diuresis) diminished with advancing chronic kidney disease (CKD) stage and concomitant deterioration of the renal function. Furthermore, advanced CKD was a significant negative predictor for the body weight (BW) responders (2.0% decrease in the body weight within 1 week after starting tolvaptan). As compared with non-CKD, the presence of advanced CKD predicts poor diuretic response for both UV and BW responders., Conclusions: The diuretic response following tolvaptan administration gradually diminished with progressive deterioration of the CKD stage. Worsening renal function was not observed. Tolvaptan is effective in treating CS2 or CS3 ADHF patients who present fluid retention and congestion, suggesting its potential efficacy for fluid management in the ADHF patients with CKD without worsening the renal function., (© 2017 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Relations between time and rhythm perception are discussed in this review of psychophysical research relevant to the multiple-look effect and dynamic-attending theory. Discrimination of two neighboring intervals that are marked by three successive sounds is improved when the presentation of the first (standard, S) interval is repeated before that of the second (comparison, C), as SSSSC. This improvement in sensitivity, called the multiple-look effect, occurs because listeners (1) perceive regular rhythm during the repetition of the standard interval, (2) predict the timing of subsequent sounds, and (3) detect sounds that are deviated from the predicted timing. The dynamic-attending theory attributes such predictions to the entrainment of attentional rhythms. An endogenous attentional rhythm is synchronized with the periodic succession of sounds marking the repeated standard. The standard and the comparison are discriminated on the basis of whether the ending marker of the comparison appears at the peak of the entrained attentional rhythm. This theory is compatible with the findings of recent neurophysiological studies that relate temporal prediction to neural oscillations.

The self includes complicated and heterogeneous functions. Researchers have divided the self into three distinct functions called "agency," "ownership," and "narrative self". These correspond to psychiatric symptoms, behavioral characteristics and neural responses, but their relationship with brain structure is unclear. This study examined the relationship between the subjectivity of self-related malfunctions and brain structure in terms of gray matter (GM) volume in 96 healthy people. They completed a recently developed self-reported questionnaire called the Embodied Sense of Self Scale (ESSS) that measures self-related malfunctions. The ESSS has three subscales reflecting the three distinct functions of the self. We also determined the participants' brain structures using magnetic resonance imaging (MRI) and voxel-based morphometry (VBM). Multiple regression analysis revealed a significant negative correlation between ownership malfunction and the insular cortex GM volume. A relationship with brain structure could thus only be confirmed for the ESSS "ownership" subscale. This finding suggests that distinct brain structures feel ownership and that the ESSS could partly screen for distinct brain structures.

Perceiving temporal relationships between sensory events is a key process for recognising dynamic environments. Temporal order judgement (TOJ) and simultaneity judgement (SJ) are used for probing this perceptual process. TOJ and SJ exhibit identical psychometric parameters. However, there is accumulating psychophysical evidence that distinguishes TOJ from SJ. Some studies have proposed that the perceptual processes for SJ (e.g., detecting successive/simultaneity) are also included in TOJ, whereas TOJ requires more processes (e.g., determination of the temporal order). Other studies have proposed two independent processes for TOJ and SJ. To identify differences in the neural activity associated with TOJ versus SJ, we performed functional magnetic resonance imaging of participants during TOJ and SJ with identical tactile stimuli. TOJ-specific activity was observed in multiple regions (e.g., left ventral and bilateral dorsal premotor cortices and left posterior parietal cortex) that overlap the general temporal prediction network for perception and motor systems. SJ-specific activation was observed only in the posterior insular cortex. Our results suggest that TOJ requires more processes than SJ and that both TOJ and SJ implement specific process components. The neural differences between TOJ and SJ thus combine features described in previous psychophysical hypotheses that proposed different mechanisms.

The dorsalis pedis tendocutaneous (DPTC) free flap is an ideal option for the reconstruction of the combined defect of the dorsal hand skin and multiple extensor tendons, whereas it possess not only soft tissue problems, but also symptomatic drop toe deformity in the donor site. We have corrected this drop toe deformity with a tendon transfer technique, using the extensor hallucis brevis muscle, which was preserved during the DPTC free flap harvest. The donor site exposing the transferred tendons was covered with another thin free flap. Two cases that underwent this technique exhibited satisfactory alignment and active extension of the toes. This tendon transfer technique combined with free flap coverage overcomes almost all the problems in the donor site of the DPTC free flap, achieving excellent contours of both the dorsal hand and the foot.

Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular wall motion abnormalities. It mimics the acute coronary syndrome; however, significant obstructive coronary artery disease is absent. The prognosis is relatively favorable in many cases, but complications may occur during the acute stage. Herein, we present a case of takotsubo cardiomyopathy in a 76-year-old woman. Three days after admission for persistent chest pains, the patient suddenly developed right hemiplegia, right homonymous hemianopsia, and aphasia. By diffusion-weighted magnetic resonance imaging and magnetic resonance angiography, we diagnosed acute-phase cerebral infarction caused by abrupt occlusion of the left middle cerebral artery by a thrombus, and treated it with intravenously administered tissue plasminogen activator. Three hours afterward, the patient's condition improved considerably. She was discharged 15 days after admission without any neurological sequelae. Thus, we show that takotsubo cardiomyopathy complicated by cerebral emboli can be successfully treated using tissue plasminogen activator. .

An 84-year-old woman was urgently referred to our hospital owing to persistent malaise and chest pain. Takotsubo cardiomyopathy was diagnosed following transthoracic echocardiography, emergency coronary angiography, and left ventriculography. A left ventricular pressure tracing during cardiac catheterization revealed a 72 mmHg-intraventricular pressure gradient (LVPG). Although β-blockers are effective at reducing LVPG in takotsubo cardiomyopathy, such treatment was contraindicated in our patient owing to her history of bronchial asthma. Therefore, we administered intravenous cibenzoline succinate to attenuate her LVPG. The LVPG decreased to 18 mmHg within 10 min after intravenous cibenzoline succinate administration. During her subsequent hospitalization, the patient showed excellent functional recovery, without any complications. Left ventriculography, performed 21 days after admission, showed normal wall motion and a left ventricular ejection fraction of 68%. < Learning objective: The prognosis of takotsubo cardiomyopathy is generally good, however, fatal complications have been reported. Our case demonstrated a LVPG of 72 mmHg, and β-blockers were contraindicated because of bronchial asthma. Intravenous cibenzoline administration resulted in successful attenuation of the patient's LVPG. The present case suggests that cibenzoline might be effective for the treatment of takotsubo cardiomyopathy, especially in those contraindicated for β-blocker therapy.>.

A 16-year-old boy stayed in Tokyo near Yoyogi Park for extracurricular high school activities. After returning home, he experienced an episode of fever and visited our emergency outpatient unit. He initially exhibited symptoms of leukopenia, thrombocytopenia and concomitant rhabdomyolysis and after admission simultaneously developed a biphasic fever and systemic erythema. Based on the results of reverse transcription polymerase chain reaction testing, he was finally diagnosed with dengue fever. After an absence of 70 years, dengue fever has reemerged as a domestic infection. Awareness of this trend led to our diagnosis.

Transcranial magnetic stimulation (TMS) has often been used in conjunction with electroencephalography (EEG), which is effective for the direct demonstration of cortical reactivity and corticocortical connectivity during cognitive tasks through the spatio-temporal pattern of long-latency TMS-evoked potentials (TEPs). However, it remains unclear what pattern is associated with the inhibition of a planned motor response. Therefore, we performed TMS-EEG recording during a go/stop task, in which participants were instructed to click a computer mouse with a right index finger when an indicator that was moving with a constant velocity reached a target (go trial) or to avoid the click when the indicator randomly stopped just before it reached the target (stop trial). Single-pulse TMS to the left (contralateral) or right (ipsilateral) motor cortex was applied 500 ms before or just at the target time. TEPs related to motor execution and inhibition were obtained by subtractions between averaged EEG waveforms with and without TMS. As a result, in TEPs induced by both contralateral and ipsilateral TMS, small oscillations were followed by a prominent negative deflection around the TMS site peaking at approximately 100 ms post-TMS (N100), and a less pronounced later positive component (LPC) over the broad areas that was centered at the midline-central site in both go and stop trials. However, compared to the pattern in go and stop trials with TMS at 500 ms before the target time, N100 and LPC were differently modulated in the go and stop trials with TMS just at the target time. The amplitudes of both N100 and LPC decreased in go trials, while the amplitude of LPC decreased and the latency of LPC was delayed in both go and stop trials. These results suggested that TMS-induced neuronal reactions in the motor cortex and subsequent their propagation to surrounding cortical areas might change functionally according to task demand when executing and inhibiting a motor response.

Background: An impaired myocardial perfusion state after primary angioplasty is a strong predictor of long-term adverse outcomes in patients with STEMI. We assessed the relationship between culprit plaque characteristics and myocardial perfusion state after primary angioplasty in patients with ST-segment elevation myocardial infarction (STEMI)., Methods: A total of 101 consecutive patients with de novo STEMI were divided into 3 groups according to the state of myocardial perfusion assessed by ST-segment elevation resolution (STR): Group A (complete: STR ≥ 70%, n=26), Group B (partial: STR<70% but ≥ 30%, n=55) and Group C (none: STR<30%, n=20). We analyzed plaque features by virtual histology intravascular ultrasound (VH-IVUS) and assessed the relationship between culprit plaque characteristics and STR after primary angioplasty., Results: Total plaque volume was significantly higher in Group C than in Groups A and B (146.4 ± 38.0 mm(3)vs. 93.3 ± 29.1 mm(3) and 105.8 ± 31.5 mm(3), p<0.001, respectively). Necrotic core (NC) volume was also significantly higher in Group C than in Groups A and B (25.4 ± 8.0m m(3), vs. 11.9 ± 6.3 mm(3) and 17.3 ± 9.7 mm(3), p<0.001, respectively). Analysis of receiver-operating characteristic curves revealed that total plaque volume and NC volume had the best diagnostic accuracy of all the VH-IVUS parameters to predict STR<30%. The optimal cutoff values (sensitivity/specificity) were 123.4 mm(3) (75.0%/75.3%) for total plaque volume and 20.3mm(3) (75.0%/74.1%) for NC volume., Conclusions: Culprit plaque with large plaque burden and high NC volume is closely associated with poor STR after revascularization., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Introduction: To prevent postoperative pharyngocutaneous fistula (PCF) after total (pharyngo)laryngectomy, simultaneous coverage of pharyngeal anastomosis with vascularised flaps such as pectoralis major muscle, anterolateral thigh or radial forearm, has been reported to be effective. As an alternative to the invasive methods using distant flaps, we used the infrahyoid myofascial flap (IHMFF), which was harvested from the same operation field of (pharyngo)laryngectomy, for covering the site of pharyngeal anastomosis. Herein, we describe the safety and effectiveness of our minimally invasive method for preventing PCF., Methods: Eleven patients who were at a high risk of developing PCF due to previous chemoradiotherapy underwent simultaneous coverage of pharyngeal anastomosis with IHMFF after total (pharyngo)laryngectomy. The incidence of PCF and the rate of major fistula requiring surgical closure were determined, and the results were compared with the control group (23 patients without IHMFF cover after laryngectomy)., Results: PCF developed in 2 of the 11 patients (18.2%). The fistulae of these two patients were closed conservatively and did not require additional surgery. PCF developed in 6 of 23 patients (26.1%) in patients without IHMFF cover. All the six patients with fistula required additional closure surgery. The incidence of PCF did not differ in patients with or without IHMFF cover (Fisher's exact probability test; p=0.939, NS). However, the rate of major PCF requiring surgical closure was significantly lower in patients with IHMFF cover (Fisher's exact probability test; p=0.036<0.05)., Conclusions: For (pharyngo)laryngectomy patients, IHMFF cover is a minimally invasive method that can prevent major PCF., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: Microsurgery is difficult to perform in necks that have been previously irradiated and operated upon because of the limited availability of recipient vessels. The objective of this study was to clarify the feasibility and safety of performing microsurgery in necks that are scarred and fibrous owing to previous treatment., Methods: Twenty patients whose necks were previously irradiated and operated upon and who underwent free tissue transfer were included in this study. All patients had been previously administered an average of 60.7 (range, 30-95)Gy of radiotherapy. Thirteen patients had undergone hemilateral neck dissections, 5 patients had undergone bilateral neck dissections, 8 patients had undergone (pharyngo)laryngectomies, and 10 patients had undergone prior flap transfer. The success rate of microsurgery and the selection of recipient vessels were examined., Results: All recipient vessels could be adopted in the neck field without vessel grafting. One patient developed necrosis of the flap, which was salvaged with retransfer of another flap after trimming the same cervical vessels. For the remaining 19 patients, free tissue transfers were successful., Conclusions: Suitable recipient vessels are residual and available even in the previously irradiated and operated neck field. When performed properly, free tissue transfer in the previously treated neck is not as risky a surgery as was generally believed., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Reconstruction of a tracheal defect is a challenge because it often requires invasive surgery associated with relatively high morbidity. We recently invented a less-invasive method using a modified infrahyoid myocutaneous (IHMC) flap for the reconstruction of a tracheal defect in an 83-year-old male. A tracheal defect, the right half of the cricoid cartilage plus the right three quarters of the I-IV tracheal cartilage (about 3 × 4 cm), was reconstructed with a modified IHMC flap composed of the sternohyoid and platysma muscles and a skin pedicle. Considering the age of patient, we avoided rigid reconstruction and used a soft silicone tracheal opening retainer (Koken Co., Ltd., Tokyo, Japan) as an anterior wall dilator after surgery and waited for the scarring of the flap until it become rigid enough. The postoperative course was uneventful and the trachea was reconstructed safely. Tracheal reconstruction with an IHMC flap is a useful and less-invasive alternative compared to end-to-end anastomosis or reconstruction with a forearm flap, which is currently used as a mainstay., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Chylous fistula is a distressing complication resulting from thoracic duct injury during neck dissections. We have successfully managed chylous fistula using negative-pressure wound therapy (NPWT) in a case where all conservative treatments failed. A 60-year-old man with tongue cancer underwent subtotal glossectomy and bilateral neck dissections. On postoperative day 4, a chylous fistula with large drainage developed in the right neck. Conservative treatments were not effective, therefore, NPWT was started from postoperative day 9. The drainage volume then began to decrease, and the chylous fistula was closed 6 days after starting NPWT. In our case, the effects of wound shrinkage and fluid removal by NPWT were considered to contribute to early closure. Although preliminary, NPWT can be an important treatment choice for the management of a chylous fistula after neck dissections., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Free flaps are considered to revascularize from the surrounding tissue and survive without their original pedicle flow after a certain period postoperatively. We report 2 patients who developed mucosal ischemia of the transferred jejunum by ligation of its vascular pedicle 10 and 25 months after microvascular free jejunal transfer. Both patients had a history of heavy smoking, and had undergone definitive radiotherapy and previous surgery to the recipient bed. Both were treated conservatively; however, a stenotic change of the transferred jejunum remained in 1 patient. If poorly revascularized flaps, such as jejunal flaps, were transferred to the irradiated and scarred recipient bed, revascularization might never reach completion. If pedicle division is required in such cases, reanastomosis of the pedicle would be ideal regardless of the time after the transfer.

Objective: Through our experiences in the parapharyngeal space (PPS) surgery, we have learned that it is possible to gain wide exposure of the PPS near to the skull base with a transcervical approach alone. Thus, we presumed that if this type of transcervical approach would be combined with a transoral approach, a less invasive oropharyngectomy without mandibulotomy and lip-splitting might be feasible for the resection of advanced oropharyngeal cancer, sparing the morbidities associated with conventional mandibular swing approach or its modified procedures. We termed this method as a mandible preserving pull-through oropharyngectomy (MPPO) and evaluated its feasibility and efficacy in this pilot study., Materials and Methods: MPPO was applied for a series of 7 patients with advanced lateral and/or upper oropharyngeal cancer including 2 patients with T4 stage. Our current application of MPPO excludes tumors, which involves mandibular bone, the higher part of the medial pterygoid muscle, and the lateral pterygoid muscle., Results: Safe and sufficient excision of tumors was feasible by MPPO avoiding morbidities associated with mandibulotomy or lip-splitting without compromising oncological outcomes., Conclusions: Although preliminary, our favorable outcomes indicate that MPPO might be a useful alternative to conventional mandibular swing approach or its modified procedures for selected cases with advanced oropharyngeal cancer. Further accumulation of data is encouraged., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: Our purpose was to establish a technique to reduce residual artifacts after transcranial magnetic stimulation (TMS) from electroencephalographic (EEG) signals., Methods: We investigated the effects of coil direction and stimulus intensity on residual artifacts in an artificial circuit, and tested whether or not the size of the circuit area affects the residual artifact (the model study). Based on the results, the optimization by rearranging the electrode's lead wire was tested on the human scalp (the human study)., Results: The residual artifact after TMS was dependent on the direction of the figure-of-eight coil, and on the artificial circuit area size., Conclusions: In accordance with the model study, the scalp EEG shows that TMS-induced artifacts can be reduced dramatically before the amplifier input stages in TMS-EEG experiments by a step-wise procedure rearranging the lead wires relative to the fixed coil orientation., Significance: Our technique makes it possible to significantly reduce the residual artifacts from recordings of short-latency TMS-evoked potentials., (Copyright © 2010 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: Plaque rupture plays a critical role for the development of acute myocardial infarction. However, whether quantitative parameters with regard to the cavity size of ruptured plaque are associated with no-reflow (NR) phenomenon following primary angioplasty remains to be elucidated., Methods and Results: A total of 53 patients with de novo ST-elevation myocardial infarction (STEMI) who had plaque rupture at the culprit lesion defined by pre-intervention virtual histology intravascular ultrasound (VH-IVUS) were enrolled. Patients were divided into two groups according to the presence of NR phenomenon: NR group (n=19) and non-NR group (n = 34). By VH-IVUS, we evaluated cavity length, maximum area, and volume of ruptured plaque in culprit lesions. The cavity length, maximum area, and volume were significantly higher in the NR group than those of the non-NR group (4.8 ± 2.1 mm vs. 2.9 ± 4.8 mm, p < 0.001; 3.6 ± 1.4 mm² vs. 1.9 ± 0.5 mm², p < 0.001; 11.5 ± 6.3 mm³ vs. 3.7 ± 2.2 cm³, p < 0.001). A multiple logistic regression analysis revealed that the cavity volume was an independent risk for NR phenomenon. Receiver-operating characteristic analysis revealed that the cavity volume could predict NR phenomenon., Conclusions: The cavity size of ruptured plaque is closely associated with NR phenomenon in patients with STEMI. Evaluation of the cavity volume by VH-IVUS may provide useful information for the prediction of NR phenomenon., (Copyright © 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Musician's dystonia is a type of task specific dystonia for which the pathophysiology is not clear. In this study, we performed functional magnetic resonance imaging to investigate the motor-related brain activity associated with musician's dystonia. We compared brain activities measured from subjects with focal hand dystonia and normal (control) musicians during right-hand, left-hand, and both-hands tapping tasks. We found activations in the thalamus and the basal ganglia during the tapping tasks in the control group but not in the dystonia group. For both groups, we detected significant activations in the contralateral sensorimotor areas, including the premotor area and cerebellum, during each tapping task. Moreover, direct comparison between the dystonia and control groups showed that the dystonia group had greater activity in the ipsilateral premotor area during the right-hand tapping task and less activity in the left cerebellum during the both-hands tapping task. Thus, the dystonic musicians showed irregular activation patterns in the motor-association system. We suggest that irregular neural activity patterns in dystonic subjects reflect dystonic neural malfunction and consequent compensatory activity to maintain appropriate voluntary movements.

Objectives/hypothesis: Salvage surgery after definitive chemoradiotherapy is often associated with a higher rate of perioperative complications and poor prognosis. The objective of this study is to examine the safety and efficacy of free jejunal transfer after salvage pharyngolaryngectomy for patients with locally recurrent hypopharyngeal carcinoma after definitive chemoradiotherapy., Study Design: A retrospective analysis of patients with advanced hypopharyngeal carcinoma who underwent pharyngolaryngectomy and reconstruction using free jejunum., Methods: Forty patients who underwent pharyngolaryngectomy with jejunal transfer were included in this study. Fourteen patients underwent surgery after definitive chemoradiotherapy (the salvage-surgery group), whereas 26 patients underwent surgery after planned preoperative chemoradiotherapy (the planned-surgery group). The perioperative conditions, mortality, morbidity, functional outcomes, and oncologic outcomes in each group were compared., Results: The patients in the salvage-surgery group lost an average of 9 kg in weight before surgery, which thus indicated a malnourished condition. However, the incidence of all perioperative complications did not differ significantly between the groups. All patients in both groups achieved oral intake without tube feeding, and the intervals to start oral intake were 12.8 days in the salvage-surgery group and 15.6 days in the planned-surgery group, which was not significantly different. The 5-year disease-free survival was 57.1% in the salvage-surgery group and 50.4% in the planned-surgery group, which was not significantly different., Conclusions: Salvage pharyngolaryngectomy and jejunal transfer can be performed safely and reliably for patients with locally recurrent hypopharyngeal carcinoma, and it is an excellent option after a failure of definitive chemoradiotherapy.

Stereotyped behaviors should be inhibited under some circumstances in order to encourage appropriate behavior. Psychiatrists have used the modified rock-paper-scissors (RPS) task to examine the inhibition of stereotyped behavior. When subjects are required to lose in response to a gesture, it is difficult for them to lose, and they have a tendency to win involuntarily. It is thought that the win response is the stereotyped response in the RPS task, and the difficulty in making positive attempts to lose is due to the requirement for inhibition of the stereotyped response. In this study, we investigated the brain regions related to inhibition of the stereotyped response using functional magnetic resonance imaging (fMRI). Subjects were assigned to one of two groups: the "win group" or the "lose group." The lose group showed higher activation of the left dorsolateral prefrontal cortex (DLFPC) when compared to the win group. We also delivered transcranial magnetic stimulation (TMS) while the subjects performed the modified RPS task to investigate whether the left DLPFC (middle frontal gyrus, Brodmann area, BA 9) was directly involved in the inhibition of the stereotyped response. When TMS was delivered before onset of the visual stimulus, the subjects displayed increased response errors. In particular, the subjects had a tendency to win erroneously in a lose condition even though they were required to lose. These results indicate involvement of the left DLPFC in inhibition of the stereotyped responses, which suggests that this region is associated with inhibition of the preparatory setting for stereotyped responses rather than inhibition of ongoing processing to produce a stereotyped response.

Thymidylate synthase (TS) is a major target of 5-fluorouracil (5-FU) and dihydropyrimidine dehydrogenase (DPD) is a rate-limiting enzyme in the degradation of 5-FU. There are no studies investigating the comparison of TS and DPD mRNA expressions in oral tongue SCC (OSCC) and nontumor tissues obtained from the same patients. In addition, increased interest has been focused on the biological roles of TS and DPD as the independent prognostic factors as well as responsive determinants for cancer patients with 5-FU based therapy. We determined the expression levels of TS and DPD in tumor (T) and nontumor squamous epithelial tissues (N) of OSCC using real-time reverse transcription-polymerase chain reaction and evaluated whether the T/N ratio would correlate with clinicopathological factors. The mRNA expressions of TS and DPD were significantly higher in tumor areas than in nontumor areas. No correlation was found between the T/N ratio of each mRNA expression and gender, clinical stage, T classification, N classification or differentiation. The T/N ratio of TS in patients that died of disease was significantly higher than in patients with free of disease, whereas there were no relationships between The T/N ratio of DPD and disease status. Clinical follow-up data showed shorter overall survival periods for cases with high T/N ratio of TS than for cases with low T/N ratio of TS with the statistically significant. Our study showed that TS but not DPD seems to have prognostic value in OSCC. These findings suggest that the assessment of TS activity may be useful both in the management and in the treatment of OSCC.

Objectives/hypothesis: To examine the efficacy and safety of free jejunal transfer after larynx-preserving esophagectomy in patients with cervical esophageal carcinoma, especially with a high tumor involving the hypopharynx., Study Design: A retrospective analysis of patients with cervical esophageal carcinoma who underwent free jejunal transfer after larynx-preserving esophagectomy., Methods: The subjects were 32 patients who underwent larynx-preserving cervical esophagectomy and microvascular jejunal transfer. Fifteen patients had a high cervical esophageal carcinoma that involved the hypopharynx (high-tumor group), and 17 patients had a low cervical esophageal carcinoma that did not involve the hypopharynx (low-tumor group). For each group, mortality, morbidity (anastomotic leakage, wound infection, stricture, and recurrent laryngeal nerve palsy), functional outcomes (time to start oral intake, achieve complete oral intake, decannulation, and rate of larynx preservation), and oncologic outcomes (survival and local control rate) were reviewed and compared., Results: No perioperative deaths occurred in either group. The incidence of postoperative complications did not differ between the groups. Oral intake started significantly later in the high-tumor group (14.9 days) than in the low-tumor group (10.4 days), but all patients in the high-tumor group could finally achieve oral intake without aspiration. Decannulation was possible in patients who underwent tracheostomy, and laryngeal function was completely preserved in the high-tumor group. Both survival and local control rate did not differ between the groups., Conclusions: Free jejunal grafts in larynx-preserving surgery can be performed safely and reliably in patients with low cervical esophageal carcinomas and in selected patients with high tumors involving the hypopharynx.

Understanding changes in attitudes towards others is critical to understanding human behaviour. Neuropolitical studies have found that the activation of emotion-related areas in the brain is linked to resilient political preferences, and neuroeconomic research has analysed the neural correlates of social preferences that favour or oppose consideration of intrinsic rewards. This study aims to identify the neural correlates in the prefrontal cortices of changes in political attitudes toward others that are linked to social cognition. Functional magnetic resonance imaging (fMRI) experiments have presented videos from previous electoral campaigns and television commercials for major cola brands and then used the subjects' self-rated affinity toward political candidates as behavioural indicators. After viewing negative campaign videos, subjects showing stronger fMRI activation in the dorsolateral prefrontal cortex lowered their ratings of the candidate they originally supported more than did those with smaller fMRI signal changes in the same region. Subjects showing stronger activation in the medial prefrontal cortex tended to increase their ratings more than did those with less activation. The same regions were not activated by viewing negative advertisements for cola. Correlations between the self-rated values and the neural signal changes underscore the metric representation of observed decisions (i.e., whether to support or not) in the brain. This indicates that neurometric analysis may contribute to the exploration of the neural correlates of daily social behaviour.

Background: Because of the low incidence of late thrombosis in free flaps used for head and neck reconstruction, the risk factors, prognosis, and the optimal method of treatment are unclear., Methods: The timing of thrombosis, types of flaps, occluded vessels, causative factors, previous irradiation, and salvage rates were reviewed and compared between 79 patients who had thrombosis on postoperative day 4 or earlier (early-thrombosis group) and 24 patients who had thrombosis on postoperative day 5 or later (late-thrombosis group)., Results: The main causative factor for thrombosis in the late-thrombosis group was wound infection (54%), whereas wound infection was present in only 1% of cases of thrombosis in the early-thrombosis group. None of the flaps could be salvaged in the late-thrombosis group., Conclusion: Poor salvage rate in the late-thrombosis group is the most serious problem. Prevention, early detection, and appropriate management of wound infection are essential for avoiding late thrombosis.

Stereotyped responses must be suppressed at certain times during daily life, which can be difficult for patients with lesions in the frontal cortices. Neuropsychologists have used the rock-paper-scissors (RPS) task to evaluate patients' ability to suppress a stereotyped response. In this study, we measured functional magnetic resonance imaging signals to investigate how frontal cortex activities change corresponding to subjects' performance as they tried to lose (successfully inhibiting the typical response to win) when presented with a gesture signifying rock, paper, or scissors. Performance rates ranged from 50% to 100%, and results indicated that activation in the bilateral anterior part of the prefrontal cortex increased parametrically corresponding to subjects' successful performance. This result implies that the anterior prefrontal cortex plays a key role in the successful completion of a modified RPS task and may play a role in the suppression of stereotyped responses.

The localization and expression of neurotrophins and their receptors during distraction osteogenesis was investigated in 72 male rat femurs (11 weeks old) to further clarify the concurrence of cellular and molecular events of new bone formation. After osteotomy, a 7-day lag phase was followed by distraction at the rate of 0.25 mm/12 h for 21 days (distraction phase), and a 7-day consolidation phase. The localization of neurotrophins (NGF, BDNF and NT-3) and their receptors tropomyosinrelated kinases (TRKA, TRKB and TRKC) by immunostaining showed positive staining in bone forming cells in each stage, although the presence and staining intensity varied by cell type and phase. The expressions of NGF, BDNF and NT-3 by real-time polymerase chain reaction (real-time PCR) showed that the peak of the mRNA expression of NGF occurred 10 days after distraction. NT-3 increased during bone extension, but decreased when distraction stopped. In contrast, BDNF continued to increase gradually throughout the distraction and consolidation phases. These findings suggest that neurotrophins and their receptors may play different roles in endochondral and intramembranous ossification in distraction osteogenesis. The tension stress caused by distraction may stimulate the expression of neurotrophins and their receptors, and promote osteogenesis.

Background and Objectives: No organized data regarding the blood losses associated with musculoskeletal tumor surgery has been existed. The present study aimed to examine the extent of blood loss and the transfusion requirement associated with various kinds of musculoskeletal tumor surgeries in a large, well-defined sample., Methods: The records of 1,047 consecutive operations for musculoskeletal tumors were reviewed., Results: The total blood loss ranged from 0 to 26,050 ml (median: 95 ml). The operative time ranged from 5 to 1,140 min (median: 105 min). There was a significant correlation between the total blood loss and the operative time. The median blood loss was 10 ml in biopsies, 100 ml in curettages, 190 ml in amputations or disarticulations, 30 ml in marginal resections (bone tumors, 50 ml; soft tissue tumors, 25 ml), and 380 ml in wide resections (bone tumors, 2,155 ml; soft tissue tumors, 180 ml). Wide resections for malignant tumors were associated with significantly more blood loss than marginal resections for benign ones. Resections of bone tumors were accompanied by significantly more blood loss than those of soft tissue tumors. Overall, blood transfusions were required after 210 (20.1%) operations., Conclusions: Our results provide the first exhaustive data about blood loss and the subsequent need for transfusion associated with various kinds of musculoskeletal tumor surgeries that may be helpful for establishing a guideline for perioperative patient management.

We investigated the effect of movement rate on the time-series properties of human synchronization errors by applying power spectrum analysis and detrended fluctuation analysis (DFA). Participants were required to execute a finger-tapping task with their right index finger in synchrony with periodic sounds under seven conditions of movement rates ranging from 1 to 4 Hz and separated by 0.5 Hz. At slow movement rates (1 and 1.5 Hz), the power spectrum of the synchronization errors flattened in the low-frequency portion, resulting in short-range correlation. At fast movement rates (from 2 to 4 Hz), on the other hand, the time series of the timing errors exhibited a 1/fbeta-type long-range correlation. These results indicate that the movement rate has an effect on the temporal coordination pattern in the human timing control mechanism. We inferred that this change in the coordination pattern reflects the transition between different states in human synchronization movements with an external signal.

We report a patient with subglottic stenosis who required insertion of the Montgomery T-tube. During the operation, we could keep stable anaesthesia and adequate ventilation under general anaesthesia using continuous intravenous infusion of propofol with laryngeal mask airway (LMA).

We investigated the difference between brain activities in speeded and precisely timed responses to identical visual stimulus using fMRI. Stimulus used was a row of seven light-emitting diodes (LEDs) lightened up one after another with constant speed within a trial but with various speeds between trials. Subjects were asked to execute finger-thumb tapping with the right hand in response to the onset of the first LED light in the reaction time (RT) task and in anticipation of the onset of the last (i.e., seventh) LED light in the timing task. In control condition, they were asked to passively view the stimulus without motor response. Results showed that various movement-related areas including contralateral cingulate motor cortex were commonly activated for both tasks relative to the control condition, suggesting these structures are involved in general perception and response execution rather than specific function for speeded or precisely timed responses. In the RT task, the presupplementary motor area extending to the cingulate sulcus was activated more strongly than in the timing task probably to focus attention to the onset of the first LED light unpredictably presented after random foreperiods. The lateral occipital area extending to the temporo-parieto-occipital junction was activated more strongly in the timing task than in the RT task; the same area was deactivated in the RT task relative to the control condition. Auditory-related areas were also deactivated in the both tasks. This inter- and intramodal task-specific modification including deactivation underscores significance of the context for perception and action and can have an important role in dexterous or skilled performance., (Copyright 2004 Elsevier Inc.)

In the absence of vision of the limb, movements toward a visual target exhibit substantial errors which are considered to originate mainly in the visuomotor transformation process. To determine the time-dependent property of human visuomotor transformation, we investigated the error sequences in movements toward visual target using scaling analyses. When subjects could see their controlling limb, the error sequences could not be distinguished from a random sequence. On the other hand, when the controlling limb was invisible, the error sequences were not random in order, but exhibited 1/f-type time correlation. This finding that the variation in human visuomotor transformation shows 1/f-type fluctuation provides a significant index for mathematical modeling and system identification in human visuomotor control., (Copyright 2004 Lippincott Williams and Wilkins)

To investigate the localization and expression of connective tissue growth factor/hypertrophic chondrocyte-specific gene product 24/CCN family member 2 (CTGF/Hcs24/CCN2) during distraction osteogenesis in the rat femur, we studied a total of 54 male rats (11 weeks old). We performed osteotomy in the midshaft of the right femur. After 7 days (lag phase), distraction was started, at the rate of 0.25 mm/12 h for 21 days (distraction phase) by using a small external fixator, and this was followed by a 7-day consolidation phase. Localization and expression of CTGF/Hcs24 during distraction osteogenesis in the femur were examined by immunostaining, in situ hybridization, and reverse transcriptase polymerase chain reaction (RT-PCR). Immunostaining showed the localization of CTGF/Hcs24 in various cells located in the bone-forming area around the osteotomy site. During the distraction phase, in situ hybridization showed that CTGF/Hcs24 mRNA was expressed not only in hypertrophic chondrocytes and osteoblasts but also in fibroblast-like cells and mesenchymal cells at sites of end-ochondral ossification, and not only in osteoblasts but also in pre-osteoblasts and fibroblast-like cells at sites of intramembranous ossification. RT-PCR showed higher level expression of CTGF/Hcs24 mRNA in the distracted group than in the nondistracted group. These results revealed an elevated pattern of CTGF/Hcs24 mRNA expression during distraction osteogenesis, and suggest that CTGF/Hcs24 may play some roles in the endochondral and intramembranous ossification processes that occur during distraction osteogenesis.

Long-term follow-up results of open reduction for developmental dislocation of 83 hips via the extensive anterolateral approach were retrospectively analyzed. Open reduction was performed in infancy, and the follow-up period ranged from 12 to 24 years. This procedure is a complete circumferential dissection of the joint capsule and produces sufficient concentric reduction of the femoral head in the acetabulum immediately after the surgery. A lateral arthrographic classification of interposed limbus and the preoperative position of the unreduced femoral head is introduced, and is related to operative findings and surgical results, including Severin's classification. The results at the final follow-up were: Severin's group I in 35 hips, group II in 19 hips, group III in 10 hips, and group IV in four hips. According to the classification of the preoperative position of the femoral head, there were 31 hips of the intracapsular type and 37 hips of the extracapsular type. Thirty-four of the 37 hips of the extracapsular type were classified in Severin's group I or II (92%). Twenty of the 31 hips of the intracapsular type were classified in Severin's group I or II (65%). A very significantly greater number of hips with good radiological outcome were in the extracapsular type than in the intracapsular type.

We examined the phenomenon of thermotolerance induction in the radioresistant prokaryote, Deinococcus radiodurans, which was initially exposed to 30 min at 52 degrees C followed by various intervals up to 6 h at 30 degrees C in TGY medium and then re-exposed to 52 degrees C for various periods, i.e., split-dose hyperthermia. This thermotolerance induction was analyzed in DNA repair deficient mutants (strain 302, 251, UVS25, rec30 and KH840) and the wild-type strain MR1. The strain UVS25 is a double mutant for the mtcA and uvsD genes, and strain rec30 is a mutant for the deinococcal recA gene. The induction was suppressed to 1/10 and 1/25 in strains UVS25 and rec30 respectively, as compared with the maximum level in the wild-type strain MR1. However, the induction in strain 302 (mutant for the uvrA gene) was not suppressed. Therefore, we conclude that proteins synthesized during the interexposure interval, i.e., the products of the uvsD (UV endonuclease beta) and recA (RecA protein) genes contribute to the induction of thermotolerance in D. radiodurans.

Background: Oral squamous cell carcinoma (SCC) develops from pre-malignant lesions, but the role of cell adhesion molecules such as E-cadherin (E-CD) and P-cadherin (P-CD) in the pre-malignant stage has not been elucidated., Methods: The expression of E-CD and P-CD was examined immunohistochemically and biochemically in a 4-nitroquinoline 1-oxide (4NQO)-induced rat model of carcinogenesis., Results: The expression of E-CD in the pre-malignant stage was the same as that in the normal epithelium. The expression of P-CD was even throughout the prickle cell layer in the dysplasia stage. E-CD and P-CD were expressed in essentially the same locations in SCC and in the pre-malignant stage. P-CD expression was very strong in the pre-malignant stage, compared to that in normal epithelium., Conclusions: Aberrant P-CD expression in E-CD-positive cells may play a crucial role in the progression of the pre-malignant stage of 4NQO-induced carcinogenesis, and may activate mechanisms responsible for cell proliferation.

The proximal-to-distal segmental sequence has been identified in many sports activities, including baseball pitching and ball kicking. However, proximal-to-distal sequential muscle activity has not been identified. The aims of this study were to establish whether sequential muscle activity does occur and, if it does, to determine its functional role. We recorded surface electromyograms (EMGs) for 17 muscles from the upper extremity and abdomen during overarm throwing and detected the onset and peak times as indices of muscle activity. The following electromyographic properties were commonly identified in the participants. First, sequential muscle activity was observed from the scapular protractors to the shoulder horizontal flexors and from the shoulder horizontal flexors to the elbow extensor, but not from the elbow extensor to the wrist flexor or forearm pronator. Secondly, the external oblique contralateral to the throwing arm became activated before the ipsilateral external oblique. This sequence is considered to be very effective for the generation of high force and energy in the trunk. Thirdly, the ipsilateral external oblique began its activity almost at foot strike. Finally, the main activity of the rectus abdominis appeared just before the point of release.

To clarify the effect of acetylcholinesterase (AChE) on the pathogenesis of airway hyperresponsiveness, AChE activities in tracheal smooth muscle and lung tissue from congenitally bronchial-hypersensitive (BHS) and bronchial-hyposensitive (BHR) guinea pigs were compared. For this purpose, AChE activities were determined by measuring the rate of absorbance of tissue homogenate. Relative amounts of AChE mRNA were also evaluated by the RT-PCR method. In both tracheal smooth muscle and lung tissue from BHS, the AChE activity and the relative amount of AChE mRNA were less than those in BHR. These results suggest that the reduced AChE activity is at least a candidate for inducing airway hyperresponsiveness.

The expression balance of M2 and M3 muscarinic receptor subtypes on the pathogenesis of airway hyperresponsiveness was investigated by using two congenitally related strains of guinea pigs, bronchial-hypersensitive (BHS) and bronchial-hyposensitive (BHR). CCh-induced airway responses in vivo and in vitro were investigated by comparing the effects of muscarinic receptor subtype antagonists, and the relative amounts of M2 and M3 muscarinic receptor mRNA in tracheal smooth muscle and lung tissue were investigated. After treatment with muscarinic receptor subtype antagonists, the ventilatory mechanics (VT, Raw, and Cdyn) of response to CCh aerosol inhalation were measured by the bodyplethysmograph method. The effects of these antagonists on CCh-induced tracheal smooth muscle contraction were also investigated. The effects of M2 muscarinic receptor blockade were less but the effects of M3 muscarinic receptors blockade on the airway contractile responses were greater in BHS than in BHR. In M3 muscarinic receptor blockades, CCh-induced tracheal contractions in BHS were significantly greater than those in BHR. In tracheal smooth muscle from BHS, the relative amount of M2 muscarinic receptors mRNA was less but that of M3 muscarinic receptor mRNA was more than those in BHR. These results suggest that the high ACh level as a consequence of dysfunction of M2 muscarinic autoreceptors and the excessive effect of M3 muscarinic receptors on the airway smooth muscle may play an important role in the pathogenesis of airway hyperresponsiveness.

Induction for the expression of the metallothionein gene, CUP1, in the yeast Saccharomyces cerevisiae by cobalt was examined using a reporter gene with the promoter of this gene fused to the coding region of lacZ. The expression of the gene was induced by cobalt as well as by copper and silver ions. The activity of beta-galactosidase showed high levels after treatment with 1.0 mM cobalt chloride. It has been reported that the induction for the transcription of CUP1 by copper and silver is mediated by the Ace1 transcription factor. However, the expression of the gene by cobalt occurred in yeast cells lacking the Ace1 factor. These results suggest the presence of a novel cobalt-specific transcription factor for the CUP1 gene.

The characteristics of airway responsiveness to acetylcholine (ACh) in congenitally bronchial-hypersensitive (BHS) and bronchial-hyposensitive (BHR) guinea pigs were clarified in vivo and in vitro. We measured the change in ventilatory mechanics in response to ACh inhalation by means of the bodyplethysmograph and the contractile responses of isolated trachea to ACh and carbachol (CCh). Further, muscarinic receptor subtypes involved these responses were identified. The basal values for ventilatory mechanics in BHS were not significantly different from those in BHR. Respiratory resistance to ACh was progressively increased in a time- and dose-dependent manner in BHS. The contractile responses of tracheal smooth muscle to ACh in BHS were significantly greater than those in BHR, but CCh-induced responses in BHS and BHR were similar. ACh- and CCh-induced contractions were mediated via M3 receptors. These results suggested that the falling-down of BHS in response to ACh inhalation was caused by the strong constriction of the airway and the reduction in ventilation. Moreover, the airway hyperresponsiveness to ACh in BHS might be partly dependent on the change in acetylcholinesterase activity.

In oligotrophic waters, not only community structure but also physiological properties of heterotrophic bacteria are influenced by the concentration of organic matter.The relationship between growth rate of two facultatively oligotrophic strains ofAeromonas sp. No. 6 andFlavobacterium sp. M1 was studied in comparison with that of two eutrophic strains ofEscherichia coli 7020 andFlavobacterium sp. M2. These strains had two or three different substrate constants (Ks values) depending on substrate concentrations: Ks values for the two former were remarkably lower than those for the two latter. For instance, Ks value forAeromonas sp. No. 6 was about 8.9μM when substrate concentration was greater than 53μM and about 1.1μM when substrate concentration was less man 53μM. InE. coli the Ks value was about 260μM at greater than 5600μM and about 47μM at less than 5600μM substrate concentration.Uptake kinetics ofAeromonas sp. grown in a medium containing 2.7 mM glutamate (H-cell) and 0.11μM glutamate (L-cell) have been determined for the intact cells. H-cell had two distinct values of Km for glutamate assimilation and respiration, and L-cell had three distinct values of Km for glutamate assimilation and respiration: In H-cell Km of assimilation was 2.8×10(-7) M and 1.5×10(-4) M, and Km of respiration was 2.3×10(-7) M and 1.7×10(-4) M; in L-cell Km of assimilation was 7.4×10(-8) M, 8.3×10(-6) M, and 1.3×10(-4) M, and Km of respiration was 2.5×10(-7), 8.9×10(-6)M, and 1.7×10(-4) M. More than 60% of glutamate taken up by the H- and L-cells was respired when the substrate concentration was less than 10(-6) M, although at greater than 10(-6) M, 50% and 30% of glutamate was respired by H-cells and L-cells, respectively. These results suggest that the facultatively oligotrophic bacteria grow with high efficiency in environments with extremely low nutrient concentration, such as oligotrophic waters of lakes and ocean, as compared with in their growth in conditions of high nutrient concentraton, such as nutrient broth.

Eighteen strains of obligately oligotrophic bacteria that grow in a medium containing 1 mg of organic carbon per liter and do not grow in a rich medium (5 g/liter of nutrient) were isolated as dominant organisms from the oligotrophic water of Lake Biwa. The growth properties of these, especially of five strains, were examined. The maximum cell yield ranged from 8.5×10(4)/ml to 2.3×10(6)/ml, and their doubling times ranged from 6.6/h to 11.8/h in LT10(-4) medium (0.5 mg trypticase and 0.05 mg yeast extract in 1 liter of filtered and aged lake water). They also showed good growth in lake water medium without adding nutrients. The optimum concentrations for their growth were 5 mg/1, 5-50 mg/1, 50 mg/1, or 500 mg/1, depending on the strains. They utilized glutamate, glycine, serine, and glycolate, but not acetate, proline, or leucine. Several properties were examined. Their growth properties were very different from those of oligotrophs or oligocarbophiles isolated by other researchers.

Using several kinds of criteria for the germination of bacterial spores, germination-pH curves were drawn for Bacillus subtilis spores observed at different temperatures. The experiments revealed that optimum pH for spore germination was markedly changed by changing the incubation temperature; the optimum pH for germination was 7.4 at 37 degrees C and 5.4 at 10 degrees C. A possible mechanism involved in this phenomenon is discussed.