Successful live birth in a patient who underwent cranial radiotherapy and systemic chemotherapy by implantation of a cryopreserved blastocyst on day 7.

Preservation of fertility has been recommended for cancer-bearing patients of reproductive age before undergoing cancer treatment. However, there are many considerations and it is difficult to preserve fertility for all patients undergoing therapy for malignancies. Female cancer survivors had lower pregnancy and live birth rates compared with others that underwent assisted reproductive technologies (ARTs). We should continue to consider the issue of infertility in patients who underwent therapies for malignancies. This is the first report of a successful live birth in a patient with a cranial tumor who underwent radiotherapy and chemotherapy after implantation of an autologous embryo. The patient was a 27-year-old Japanese woman. She was diagnosed with suprasellar germinoma at 13 years of age, and she developed panhypopituitarism after radiotherapy and chemotherapy. At 27 years of age, she began infertility treatment with in-vitro fertilization (IVF). The level of anti-Mallerian hormone (AMH) was 4.29 ng/ml. After ovarian stimulation by high purified human menopausal gonadotropin (HP-hMG), she obtained two blastocysts and became pregnant by implantation of a cryopre- served blastocyst. At 37 gestational weeks, she delivered a healthy female baby by cesarean section.

Risk factors for neutropenia with lenalidomide plus dexamethasone therapy for multiple myeloma.

Neutropenia may develop as an adverse event in patients with multiple myeloma receiving lenalidomide (LEN) plus dexamethasone (DEX) therapy. In the present study, we examined the risk factors associated with grade 3/4 neutropenia during the first cycle of LEN plus DEX therapy. We observed that hemoglobin level (≤ 8.5 g/dl) was a significant risk factor for grade 3/4 neutropenia during the first cycle of therapy (odds ratio: 19.40; 95% confidence interval: 2.68-141.00; p < 0.01). thus, our findings suggest that determining the hemoglobin level could be useful in the risk management for neutropenia in patients receiving LEN plus DEX therapy.

A comparative analysis of micafungin and caspofungin for empirical antifungal therapy in antibiotic-unresponsive febrile patients with hematologic malignancies.

This study was retrospectively carried out to compare the efficacy of echinocandins such as micafungin (MCFG) and caspofungin (CPFG) in the treatment of antibiotic-unresponsive febrile patients with hematologic malignancies. A total of 163 patients received either MCFG or CPFG. We evaluated the efficacy of echinocandin against fever decline in all patients. Fever decline, defined as a body temperature of less than 37.5 °C sustained for more than 48 h without scheduled antipyretic medication. Efficacy assessments showed that the incidence of fever decline was not significantly different between the MCFG and CPFG groups (P=0.599). The median number of days from the start of echinocandin administration to fever decline was 5 in both the MCFG and CPFG groups. Multivariate analysis showed that the use of anti-MRSA drugs (HR, 0.64; 95%CI, 0.45-0.90; P=0.011) and a change from echinocandins to voriconazole or liposomal-amphotericin B (HR, 0.50; 95%CI, 0.30-0.74; P<0.001) are significant risk factors for sustained fever. A significant difference (P=0.002) in incidence of fever decline was however associated with differences in the timing of anti-MRSA drug administration. The median number of days from the start of echinocandin administration to fever decline was 5 when administration of the anti-MRSA drug occurred "simultaneously or prior to echinocandin start" and 11 in the "next day or later of echinocandin start" group. In other words, starting anti-MRSA drug treatment after echinocandin treatment is a risk factor. In conclusion, MCFG and CPFG have similar efficacy as empirical antifungal agents in the treatment of antibioticunresponsive febrile patients with hematopoietic malignancies.

Rapamycin Prolongs Cardiac Allograft Survival in a Mouse Model by Inducing Myeloid-Derived Suppressor Cells.

Mammalian target of rapamycin (mTOR) inhibitors are the main immunosuppressive drugs for organ transplant recipients. Nevertheless, the mechanisms by which mTOR inhibitors induce immunosuppression is not fully understood. Myeloid-derived suppressor cells (MDSCs) maintain host immunity; however, the relationship between mTOR inhibitors and MDSCs is unclear. Here, the results from a murine cardiac transplantation model revealed that rapamycin treatment (3 mg/kg, intraperitoneally on postoperative days 0, 2, 4, and 6) led to the recruitment of MDSCs and increased their expression of inducible nitric oxide synthase (iNOS). Immunohistochemical analysis revealed that rapamycin induced the migration of iNOS-expressing MDSCs into the subintimal space within the allograft vessels, resulting in a significant prolongation of graft survival compared with that in the untreated group (67 days vs. 7 days, respectively). These effects were counterbalanced by the administration of an anti-Gr-1, which reduced allograft survival to 21 days. Moreover, adoptive transcoronary arterial transfer of MDSCs from rapamycin-treated recipients prolonged allograft survival; this increase was reversed by the anti-Gr-1 antibody. Finally, co-administration of rapamycin and a mitogen-activated protein kinase kinase (MEK) inhibitor trametinib reversed rapamycin-mediated MDSC recruitment. Thus, the mTOR and Raf/MEK/extracellular signal regulated kinase (ERK) signaling pathways appear to play an important role in MDSC expansion.

Testing the validity and acceptability of the diagnostic criteria for Hoarding Disorder: a DSM-5 survey.

BACKGROUND: The DSM-5 Obsessive-Compulsive Spectrum Sub-Workgroup is recommending the creation of a new diagnostic category named Hoarding Disorder (HD). The validity and acceptability of the proposed diagnostic criteria have yet to be formally tested. METHOD: Obsessive-compulsive disorder/hoarding experts and random members of the American Psychiatric Association (APA) were shown eight brief clinical vignettes (four cases meeting criteria for HD, three with hoarding behaviour secondary to other mental disorders, and one with subclinical hoarding behaviour) and asked to decide the most appropriate diagnosis in each case. Participants were also asked about the perceived acceptability of the criteria and whether they supported the inclusion of HD in the main manual. RESULTS: Altogether, 211 experts and 48 APA members completed the survey (30% and 10% response rates, respectively). The sensitivity and specificity of the HD diagnosis and the individual criteria were high (80-90%) across various types of professionals, irrespective of their experience with hoarding cases. About 90% of participants in both samples thought the criteria would be very/somewhat acceptable for professionals and sufferers. Most experts (70%) supported the inclusion of HD in the main manual, whereas only 50% of the APA members did. CONCLUSIONS: The proposed criteria for HD have high sensitivity and specificity. The criteria are also deemed acceptable for professionals and sufferers alike. Training of professionals and the development and validation of semi-structured diagnostic instruments should improve diagnostic accuracy even further. A field trial is now needed to confirm these encouraging findings with real patients in real clinical settings.

Characteristics of prolonged luteal phase identified by milk progesterone concentrations and its effects on reproductive performance in Holstein cows.

A database of milk progesterone profiles consisting 497 lactations in 3 dairy herds from northern and western regions of Japan was used to identify the characteristics and associated risk factors for prolonged luteal phase (PLP) and its effects on subsequent reproductive performance in high-producing Holstein cows. Milk samples were collected twice weekly and progesterone concentrations in whole milk were determined by ELISA. Herds were visited monthly and examined by vaginoscopy and transrectal palpation. Resumption of ovarian cyclicity within 35 d postpartum followed by regular cycles was considered normal. Prolonged luteal phase was defined when progesterone concentrations were ≥5 ng/mL for ≥20 d of duration in any cycle postpartum. Delay of first ovulation to 35 to 60 d (delayed first ovulation type I), >60 d (delayed first ovulation type II), a luteal phase of <14 d except in the first cycle (short luteal phase), and the absence of luteal activity >14 d between 2 cycles (cessation of cyclicity) were the other categories of abnormal ovarian resumptions considered. The overall incidence of PLP in the 3 herds was 11.9% and a significantly higher proportion of PLP was observed in the first cycle postpartum compared with the second and third cycles. Approximately 83% of the PLP were 20 to 28 d in duration, and maximum progesterone concentration was significantly higher when PLP lasted >35 d compared with PLP of 20 to 35 d in duration. Higher parity, commencement of luteal activity≤28 d postpartum, and postpartum complications significantly increased the occurrence of PLP within 90 d postpartum. Cows with PLP showed reduced conception rate to first artificial insemination (AI) and reduced pregnancy proportions within 100, 150, and 210 d postpartum. Based on survival analysis, PLP was associated with a 56% reduction in relative pregnancy rate and a 36% reduction in AI submission rate. Cows that experienced PLP had a longer interval from calving to first AI (74 d) and from calving to pregnancy (141 d) than cows without PLP (53 and 80 d), respectively. In conclusion, 11.9% of lactations had PLP, of which approximately two-thirds were seen in the first cycle postpartum. Most of the PLP were 20 to 28 d in duration. Higher parity, postpartum complications, and early commencement of luteal activity postpartum increased the risk for PLP. Occurrence of PLP adversely affected fertility by reducing pregnancy proportions and extending calving to conception interval.

Plasma cortisol concentrations after CIDR insertion in beef cows.

The objective of this study was to show plasma cortisol concentration after treatment with controlled internal drug release (CIDR) in non-suckling beef cows. On day 9 after oestrus, two cows were inserted with CIDR into the vagina for 24 h and the other two cows were treated as a control group. Four days later, the two control cows were treated with CIDR and the other two CIDR-treated cows were used as controls. Cortisol concentrations were determined by ELISA in plasma samples collected before, during and after insertion of CIDR. There was a significant increase in plasma cortisol concentrations (p<0.01) after insertion of CIDR. Mean (± SEM) plasma cortisol concentrations increased from 1.3 ± 0.4 to a peak of 8.8 ± 1.1 ng/ml at 5 h and then decreased to basal concentrations at 7 h after insertion of the device. In conclusion, the insertion of intra-vaginal device causes an increase in plasma cortisol concentrations in beef cows, although the pathophysiological significance of the elevation of cortisol is not known.

Adrenocortical response in cows after intramuscular injection of long-acting adrenocorticotropic hormone (tetracosactide acetate zinc suspension).

The objectives of this study were first to show adrenocortical response to a long-acting adrenocorticotropic hormone preparation (tetracosactide acetate zinc suspension) (ACTH-Z) and its effect on adrenocortical function in beef cows (Experiment 1) and second to apply the ACTH-Z challenge in dairy cows based on cortisol concentrations in milk collected at routine milking (Experiment 2). In Experiment 1, four beef cows in luteal phase were challenged with ACTH-Z, and plasma cortisol concentrations were determined for 48 h after the injection at 30-min to 2-h intervals. A rapid ACTH test was conducted 3 days before and 2 h after the completion of ACTH-Z injection for 48 h to investigate the effect on adrenocortical function. Plasma cortisol concentrations increased significantly 30 min after ACTH-Z injection (p < 0.001), and the high cortisol levels were maintained for approximately 10 h after the injection. In Experiment 2, eight dairy cows were subjected to ACTH-Z challenge 1-2 weeks and 4-5 weeks post-partum. Blood and milk samples were taken at morning and afternoon milking. All the cows showed a significant increase in cortisol concentrations in plasma as well as in skim milk 8 h after ACTH-Z injection 1-2 weeks and 4-5 weeks post-partum (p < 0.001). There was a significant correlation between plasma and skim milk cortisol concentrations 8 h after ACTH-Z challenge (r = 0.74, p < 0.001). The results obtained in this study suggest that elevated levels of plasma cortisol are maintained for approximately 10 h after ACTH-Z treatment without adverse effect on adrenocortical function and a long-acting ACTH-Z challenge based on cortisol concentrations in milk, which were collected at the morning and the afternoon milking, can be a useful tool to monitor adrenocortical function in cows.

Comparison in effect of Heatsynch with heat detection aids and CIDR-Heatsynch in dairy heifers.

The objective of the present study was to determine whether oestrous detection with the help of oestrous detection aids during the Heatsynch without timed AI protocol is equally effective with the progesterone-combined protocol in dairy heifers. A total of 148 heifers were randomly assigned to one of the two groups. A group of heifers treated with Heatsynch with heat detection aids (n = 72) received GnRH on day 0, prostaglandin F(2alpha) (PGF(2alpha)) on day 7 and oestradiol benzoate (EB) on day 8, while in controlled internal drug release (CIDR)-Heatsynch group (n = 76), CIDR was included during a period from GnRH to PGF(2alpha). Heifers were checked for oestrus twice daily, i.e. from 09:00 to 10:00 hours and from 15:00 to 16:00 hours starting on day 2 for Heatsynch group and on day 8 in CIDR-Heatsynch group, and continued up to day 12. KAMAR heat mount detector (KAMAR Inc., Steamboat Springs, CO, USA) and ALL-WEATHER PAINTSTIK (LA-CO Industries Inc., Elk Grove Village, IL, USA) were used as heat detection aids. AI was conducted within 1 h after confirming oestrus in 72 heifers, while 19 animals were transferred with embryo 7 days after oestrus according to the request of the owners. Premature oestrus before PGF(2alpha) injection occurred in 18% of Heatsynch group. Of 13 heifers which showed premature oestrus, six were inseminated and two of them conceived. Oestrus detection rate within 12 days after initiation of the protocols did not differ between the two groups (94% vs 95%). There was no difference in the conception rate after first AI (including heifers that were inseminated before PGF(2alpha) injection) and embryo transfer between Heatsynch with heat detection aids and CIDR-Heatsynch groups (36% vs 44% and 70% vs 56%). It is concluded that the use of heat detection aids to monitor the occurrence of premature oestrus prior to PGF(2alpha) injection in Heatsynch protocol in dairy heifers was equally effective to the inclusion of CIDR.

Long-term efficacy of Helicobacter pylori eradication in patients with idiopathic thrombocytopenic purpura: 7-year follow-up prospective study.

Helicobacter pylori eradication is useful for improvement of a half of patients with idiopathic thrombocytopenic purpura (ITP), but its long-term therapeutic efficacy has not been elucidated. We investigated the long-term efficacy of H. pylori eradication in 30 cases with ITP that were included in our previous study regarding the association between H. pylori infection and ITP. Twenty-one cases were positive and nine cases were negative for H. pylori infection. H. pylori eradication therapy including secondary regimen was successful in 20 cases, half (responder) of whom showed ITP remission 1 month later. Nine responders could be followed up for a long time and did not show re-infection of H. pylori. Eight of nine needed no medication except for eradication therapy. Another case remained in remission for 1 year but thereafter needed a steroid therapy due to the recurrence. Eight nonresponders could be followed up for a long time. All these cases showed a bad clinical course even though they received the other post-treatments including steroid therapy. Three of nine H. pylori-negative cases underwent eradication therapy after obtaining the written informed consent, but none of them showed improvement. Of these three cases, two cases could be followed up. Only one case remained a remission although receiving corticosteroid as a post-treatment. Conditions of H. pylori-negative ITP cases were usually unstable for a long time. H. pylori eradication has a short-term efficacy for about half of H. pylori-positive ITP patients, and the responders to the eradication therapy may receive a long-term clinical benefit without other therapies.

Prevalence of urovagina and its effects on reproductive performance in Holstein cows.

Two hundred fifty-eight Holstein cows (n=344 lactations) from seven dairy herds were examined every month by vaginoscopy and transrectal palpation to determine the prevalence of urovagina, to investigate its effects on fertility, and to determine some risk factors for urovagina. Accumulation of urine in the vagina of a cow was diagnosed as urovagina and was classified into mild (urine only on the floor of vagina), moderate (urine covering less than or equal to half portion of the external cervical os), or severe (urine covering more than half or whole portion of the external cervical os). In total, 26.7% of lactations had urovagina (mild 11.3%, moderate 11.0%, and severe 4.4%). Survival analysis was used to derive the case definition of clinically relevant urovagina based on the factors associated with increased time to conception. Only moderate (hazard ratio [HR]=0.39) and severe (HR=0.20) degrees of urovagina were associated with reduction in pregnancy rate and thus defined as clinically relevant urovagina. Cows with clinically relevant urovagina had decreased AI submission rate (HR=0.52) and pregnancy rate (HR=0.35), required more inseminations per conception (5 vs. 2; P<0.001), had more days open (370 vs. 136; P<0.001), and were more likely not to get pregnant by 210 d postpartum (odds ratio [OR]=6.62) and to be culled for any reasons (OR=5.32) or for reproductive reasons (OR=9.54) compared with those in cows with no urovagina. Cows with clinically relevant urovagina had a higher risk of endometritis (36.4% vs. 9.2%; P<0.001) compared with that in cows without urovagina. Cow, low BCS at first postpartum examination (OR=2.85), endometritis within 60 d (OR=2.50), and horizontal vulva (OR=9.30) were risk factors for urovagina. In conclusion, 15.4% of lactations had clinically relevant urovagina that increased the risk of endometritis and had detrimental effects on fertility. Individual susceptibility, low BCS, and horizontal vulva increased the risk of diagnosing urovagina in Holstein cows.

Plasma progesterone profile in ovariectomized beef cows after intra-vaginal insertion of new, once-used or twice-used CIDR.

Objective of this study was to show plasma progesterone concentrations in ovariectomized beef cows after treatment with new, once-used and twice-used controlled internal drug-releasing devices (CIDRs). Four ovariectomized beef cows were used for the experiment. Plasma concentrations of progesterone were quantified using a validated ELISA. The CIDR was inserted into vagina of cows by using a standard CIDR applicator and then removed 7 days after insertion. One week later, once-used CIDR was inserted and removed on day 7. Twice-used CIDR was, then inserted at an interval of 7 days. Mean plasma concentrations of progesterone 24 h after new CIDR insertion was 4.0 +/- 0.1 ng/ml, which thereafter decreased gradually to 1.4 +/- 0.1 ng/ml at day 7. In cows treated with once-used CIDR or twice-used CIDR, mean plasma progesterone concentrations at day 1 were 2.4 +/- 0.2 or 1.8 +/- 0.2 ng/ml and 1.0 +/- 0 or 0.9 +/- 0.1 ng/ml at day 7 respectively. The results suggest that once-used CIDR may be still effective to produce luteal phase progesterone concentrations in plasma in non-suckling beef cows.

Incidence of error in oestrus detection based on secondary oestrus signs in a 24-h tie-stalled dairy herd with low fertility.

Oestrus detection error and conception rates after AI based only on secondary oestrus signs were evaluated in a high yielding, 24-h tie-stalled dairy herd with low fertility, using milk progesterone profiles. Oestrus detection was based on the secondary oestrus signs such as restlessness, swelling, congestion of vulva and clear mucus discharge. Sixty eight AI conducted after observing the secondary oestrus signs in 44 animals were included in the study. Of the 68 AI, 53 (77.9%) were conducted in the follicular phase, and 13 (19.1%) and 2 (2.9%) were carried out in the luteal phase and during pregnancy, respectively. The overall error in oestrus detection based on milk progesterone profiles was 22.1%. The oestrus detection error did not differ significantly among different secondary oestrus signs. None of the AI conducted in the luteal phase resulted in conception, whereas 20.8% of AI conducted in the follicular phase resulted in conception. No significant difference in the conception rates among the groups of cows with different secondary oestrus signs was shown. The high incidence of oestrus detection error in this study might have been caused by the detection of cows in oestrus based only on secondary oestrus signs due to the confinement of animals. In conclusion, there was a high incidence of heat detection error in the 24-h tie-stalled dairy herd and oestrus detection based only on secondary oestrus signs resulted in low conception rate.

[Antibiotic-resistant infectious thoracoabdominal aortic aneurysm; report of a case].

A 76-year-old female presented with constipation and anorexia Computed tomography (CT) revealed a saccular aneurysm (35 mm in diameter) directly over the root of the celiac artery, and she was referred to our department and was admitted. Klebsiella pneumoniae was detected in blood culture. Although antibiotics were administered, the inflammatory response was not improved. On day 8 after hospitalization, CT revealed the aneurysm increased. Therefore, surgery was performed. Aneurysm was observed adjacent to the celiac artery. The excised aorta included the descending thoracic aorta and the superior mesenteric artery, and was replaced with a rifampicin-soaked Vasctec Gelweave 24 mm vascular graft with branches. After hemostasis, omental implantation was performed around the vascular graft. Before surgery, sufficient antibiotics administration is desirable to bring the infection under control. However, if infection is uncontrollable with progressive enlargement of the aneurysm, as in this case, surgery is unavoidable. A combination of treatments was successful.

Isolated Superior Mesenteric Artery Dissection Following Liver Transplant: Report of 3 Cases.

BACKGROUND: Isolated superior mesenteric artery (SMA) dissection (SMAD) is considered a relatively rare disease. Especially, isolated SMAD following liver transplant has been rarely reported. REPORT OF CASES: Among 96 consecutive adult recipients who underwent liver transplant at our institution, 3 recipients (3.1%) demonstrated isolated noncommunicating SMAD, type IV according to Sakamoto's classification. Patient characteristics are the following: mean age, 53 years (range, 49-60 years); male to female ratio, 2:1, right lobe graft to left lobe graft ratio, 2:1; operating time, 760 minutes (range, 614-880 minutes); and blood loss, 6570 mL (range, 2435-13,329 mL). New onset of abdominal pain was noted in 33.3% (1/3). The diagnosis was made by the first follow-up computed tomography scan after liver transplant. The mean distance between the proximal end of SMAD and the root of SMA was 21.3 mm (range, 9-40 mm). There were no signs of ischemic changes in the small intestine in any of the 3 patients. Thus, conservative managements such as anticoagulation therapy were performed without other aggressive interventions. One patient died because of subarachnoid hemorrhage. In the other 2 patients, SMAD disappeared at 6 months following the diagnosis. DISCUSSION: The morbidity of isolated SMAD is around less than 0.1% at the autopsy. Compared with this result, we found significantly higher morbidity rate in liver transplant recipients. It is true that mechanical stress from retraction of the stomach to the caudal end including the root of SMA may play an important role in the onset of SMA dissection. CONCLUSION: Isolated SMA dissection following living donor liver transplant is a rare but potentially life-threatening condition. It is required to ascertain whether emergency revascularization should be considered.

PCB contamination assessment of yusho patients by using preserved human umbilical cord.

PCB concentrations in umbilical cord preserved from the time when Yusho patients and healthy subjects gave birth were examined. The total concentration of the 12 DL-PCB isomers ranged from 130 to 12,000 pg/g in the umbilical samples, was about 700 pg/g around 1950 but began to increase in the mid 1960s, reached about 12,000 pg/g between 1968 and 1970 immediately after the Yusho incident. However, the DL-PCB concentration was high between 1968 and 1970 in not only the designated Yusho patients but also healthy subjects, and the maximum DL-PCB concentration was close between the two groups.

Dexamethasone Prolongs Cardiac Allograft Survival in a Murine Model Through Myeloid-derived Suppressor Cells.

BACKGROUND: Recently, myeloid-derived suppressor cells (MDSCs) have attracted considerable attention because of their cancer-promoting and immunosuppressive effects. The glucocorticoid dexamethasone (Dex) is an important immunosuppressive agent used to treat autoimmune diseases and organ transplant rejection. However, the mechanism by which it modulates the immune system is not completely understood. MATERIAL AND METHODS: In this study, we investigated the mechanisms by which Dex modulated the immune response in mice given an allogeneic cardiac transplant. RESULTS: Dex injection significantly prolonged heart graft survival compared with phosphate-buffered saline-injected controls. Dex treatment increased the number of splenic MDSCs. Moreover, Gr-1high/CD11b+ MDSCs and CD3+/CD4+/Foxp3+ regulatory T cells (Tregs) were significantly increased in the Dex group compared with controls. Administration of anti-Gr-1 antibody (Ab) to the Dex group significantly shortened mouse heart graft survival. In addition, anti-Gr-1 Ab treatment significantly reduced Tregs in the Dex + anti-Gr-1 co-treatment group compared with the Dex group. These observations suggest that Dex treatment increased both MDSCs and Tregs, and that MDSCs regulated the incidence of Tregs in this immunosuppressive pathway. CONCLUSION: An important role of Dex in the prevention of the rejection of cardiac grafts in mice is to expand MDSCs and Tregs.

Compensatory cortical activation during performance of an attention task by patients with diffuse axonal injury: a functional magnetic resonance imaging study.

OBJECTIVE: To determine how cortical compensation occurs in higher cognitive systems during the recovery phase of diffuse axonal injury (DAI). DESIGN: 12 right-handed patients with a magnetic resonance imaging (MRI) lesion pattern compatible with pure DAI were identified. Pure DAI was defined as finding of traumatic microbleeds on T2*-weighted gradient-echo images in the absence of otherwise traumatic or non-traumatic MRI abnormalities. 12 matched healthy controls were also enrolled. Functional magnetic resonance imaging (fMRI) was used to assess brain activation during a working memory test (Paced Visual Serial Attention Test (PVSAT)). RESULTS: No significant group differences were observed in reaction times for the PVSAT. Although patients with pure DAI committed a few errors during the PVSAT, controls respond correctly to each probe. Controls showed activations in the left frontal gyrus, left parietal gyrus and right inferior parietal gyrus. Patients with pure DAI showed activations in the left inferior frontal gyrus, right inferior frontal gyrus and right middle frontal gyrus. Between-group analysis of the PVSAT task showed significantly greater activation of the right inferior frontal gyrus (BA 45) and right middle frontal gyrus (BA 9) in patient with pure DAI versus controls. CONCLUSIONS: Patients with pure DAI require compensatory activation of the contralateral (right) prefrontal region to carry out activities similar to healthy controls. These findings provide further evidence for the adaptive capacity of neuronal systems and brain plasticity during the recovery stages of DAI.

[Total aortic arch replacement for ruptured aortic arch aneurysm in a 93-year-old woman].

Semi-emergency total aortic arch replacement was performed in a 93-year-old woman with rupture of a true saccular aneurysm at the distal aortic arch. The patient had lived by herself before surgery. She was successfully treated and showed no post-operative cerebral complications. Total aortic arch replacement must be carefully planned, because this surgery is highly invasive and is associated with a high rate of complications. This surgery is sometimes inevitably performed as a life-saving procedure in very old patients. The surgical outcome however, is less favorable. Although we used the "Eaves" technique during surgery to decrease post-operative bleeding, the surgical invasiveness itself was not reduced. Further effort is needed to develop innovative procedures.