Granuloma, vasculitis, and demyelination in sarcoid neuropathy.

BACKGROUND: Despite the suggestion that direct compression by granuloma and ischemia resulting from vasculitis can cause nerve fiber damage, the mechanisms underlying sarcoid neuropathy have not yet been fully clarified. METHODS: We examined the clinicopathological features of sarcoid neuropathy by focusing on electrophysiological and histopathological findings of sural nerve biopsy specimens. We included 18 patients with sarcoid neuropathy who had non-caseating epithelioid cell granuloma in their sural nerve biopsy specimens. RESULTS: Although electrophysiological findings suggestive of axonal neuropathy were observed, particularly in the lower limbs, all but three patients showed ≥1 abnormalities in nerve conduction velocity or distal motor latency. Additionally, a conduction block was observed in 11 of the 16 patients for whom waveforms were assessed; five of them fulfilled motor nerve conduction criteria strongly supportive of demyelination as defined in the European Academy of Neurology/Peripheral Nerve Society (EAN/PNS) guideline for chronic inflammatory demyelinating polyneuropathy (CIDP). In most patients, sural nerve biopsy specimens revealed a mild to moderate degree of myelinated fiber loss. Fibrinoid necrosis was observed in one patient, and electron microscopy analysis revealed demyelinated axons close to granulomas in six patients. CONCLUSIONS: Patients with sarcoid neuropathy may meet the EAN/PNS electrophysiological criteria for CIDP due to the frequent presence of conduction blocks. Based on our results, in addition to the ischemic damage resulting from granulomatous inflammation, demyelination may play an important role in the mechanism underlying sarcoid neuropathy.

[A Case of Resection of T2N0 Colon Cancer with Synchronous Solitary Lung Metastasis].

A 73-year-old man was referred to our hospital for anemia. He underwent a colonoscopy; a 15-mm Ip polyp and a 30- mm type 1 lesion were found in the sigmoid colon. Pathological examination results indicated a well-differentiated adenocarcinoma. Thoracic computed tomography(CT)revealed a mass lesion 12 mm in diameter in the left lung lobe. The patient underwent a laparoscopic sigmoidectomy and D3 lymph node dissection and was discharged in a good condition. He then underwent a diagnostic-therapeutic segmental pulmonary resection for the pulmonary mass. Postoperative pathological findings indicated pT1b(SM), ly0, v0 and pT2(MP), ly1, v1, pN0 for the 2 lesions of the colon. The pulmonary mass was diagnosed as a metastatic adenocarcinoma based on immunostaining examination(CK7: negative, CK20: positive, TTF-1: negative, and CDX-2: positive). The patient is currently under follow-up as an outpatient without recurrence.

Ultrafast pump-probe spectroscopy via chirped-pulse up-conversion with dispersion compensation.

In this study, ultrafast transient signals were detected on a single-shot basis using chirped-pulse up-conversion spectroscopy with dispersion compensation. Unlike in the conventional time-encoding technique using chirped pulses, distortion of the ultrafast waveform was reduced by applying dispersion compensation to the chirped probe pulses and using sum-frequency generation with the chirped readout pulses. The method was applied to terahertz time-domain spectroscopy and near-infrared pump-probe spectroscopy, providing ultrafast observations with an improved temporal resolution comparable to the transform-limited pulse durations. Terahertz waveforms, Kerr rotation signals, and phonon-polariton oscillations were measured accurately with no significant waveform distortion, thereby showing the proposed scheme to be promising for single-shot pump-probe spectroscopy in a wide range of spectroscopic applications.

Wearable sensor device-based detection of decreased heart rate variability in Parkinson's disease.

The evidence that heart rate variability (HRV) decreases during early Parkinson's disease (PD) largely depends on electrocardiogram data. In this study, we examined HRV in PD using wearable sensors and assessed various evaluation methods for detecting disease-related alterations. We evaluated 27 patients with PD and 23 disease controls. The wearable sensors POLAR V800 HR and POLAR H10 were used for the HRV measurements. The participants wore the two sensors for approximately 24 h, and long-term HRV data were acquired. We analyzed the standard deviation of normal R-R intervals (SDNN) and coefficient of variation of R-R intervals (CVRR) for every 100 consecutive beats. Focusing on the fluctuation of SDNN and CVRR, we extracted the minimum, first decile, first quartile, and median values of SDNN and CVRR. The area under the receiver operating characteristic curve (AUC) for each HRV parameter was calculated to differentiate PD from the disease controls. The minimum values of SDNN and CVRR had the highest AUC (SDNN: AUC 0.90, 95% confidence interval [CI] 0.78-0.96; CVRR: AUC 0.90, CI 0.76-0.96) among the evaluation methods tested. The minimum values of SDNN and CVRR were significantly decreased in PD (SDNN: 9.5 ± 4.0 ms vs. 4.4 ± 2.0 ms, p < 0.0001; CVRR: 1.15 ± 0.33% vs. 0.65 ± 0.24%, p < 0.0001). We detected decreased HRV in PD using wearable sensors. Analyzing the minimum values of the HRV parameter in long-term recordings appears to be appropriate for detecting the decrease in HRV in PD.

Cold-Restraint Stress-Induced Ultrasonic Vocalization as a Novel Tool to Measure Anxiety in Mice.

Ultrasonic vocalization (USVs) is a promising tool to measure behavioral anxiety in rodents as USV recording is noninvasive, behaviorally relevant, ethological, and reproducible. Studies reporting the effects of stress-induced USVs in adult mice remain limited and debated. We investigated the conditions under which mice emit aversive USVs and evaluated the effects of psychiatric drugs on stress-induced USVs. Male C57BL/6J mice were used. USVs during entire stress sessions were recorded according to their frequency. To investigate the effect of psychiatric drugs on USVs, the number of USVs under cold-restraint stress conditions before and after drug administration was compared. Immediately after stress exposure, blood samples were collected and plasma corticosterone levels were measured. The combination of cold and restraint stress conditions significantly increased the USV numbers and plasma corticosterone levels compared with each stress alone. A benzodiazepine anxiolytic (midazolam) and δ-opioid receptor agonist putative anxiolytic (KNT-127) significantly reduced the stress-induced USV number and plasma corticosterone levels; however, a monoaminergic antidepressant (duloxetine) and N-methyl-D-aspartic acid receptor antagonist antidepressant (ketamine) did not reduce the USV numbers. No changes were noted in the USV numbers after repeated exposure to cold-restraint stress on days 1 and 3. The suppressive effect of midazolam on day 3 was comparable to that on day 1. Stress-induced USV may be used as a quantitative measure of anxiety to systematically assess the effects of anxiolytics. Therefore, cold-restraint stress-induced USVs may be used as a novel tool to measure rodent anxiety and as a useful anxiolytic-screening system.

Impaired pain processing and its association with attention disturbance in patients with amyotrophic lateral sclerosis.

BACKGROUND: Cognitive dysfunction characterized by executive dysfunction and persistent attention function has been reported in patients with amyotrophic lateral sclerosis (ALS); however, it is unclear if this contributes to the pain processing deficits associated with the disease. OBJECTIVE: We clarified the relationship between pain processing and both cognitive function and sensory symptoms in patients with ALS. METHODS: We enrolled 23 patients with ALS and 14 healthy control subjects. We examined pain-related somatosensory evoked potentials (SEPs) using an intra-epidermal needle electrode. We evaluated cognitive function and the clinical characteristics of sensation and analyzed their relationships with pain-related SEPs. RESULTS: Pain-related SEP amplitudes were significantly lower, while the rate of amplitude attenuation due to habituation or change in attention was significantly greater in patients with ALS than in control subjects. There were no significant differences in pain-related SEP parameters between patients with or without sensory symptoms. Instead, pain-related SEP amplitude and its rate of attenuation were correlated with cognitive dysfunction, particularly with attention domains. CONCLUSIONS: Our results suggest that attention deficit, but not sensory nerve involvement, is a major cause of the alterations in pain-related SEP in patients with ALS.

Insulin promotes sodium transport but suppresses gluconeogenesis via distinct cellular pathways in human and rat renal proximal tubules.

Insulin is known to promote sodium transport and regulate gluconeogenesis in renal proximal tubules. Although protein kinase B (also known as Akt) and mammalian target of rapamycin complexes (mTORC) have been established as key regulators in the insulin signaling pathway, their roles in proximal tubules are poorly understood. To help define this, we examined the components of insulin signaling in sodium transport and gluconeogenesis in isolated human and rat proximal tubules, and also investigated the role of insulin in sodium handling and mTORC1 in insulin signaling in vivo. In isolated human and rat proximal tubules, Akt and mTORC1/2 inhibition suppressed insulin-stimulated sodium-bicarbonate co-transporter 1 (NBCe1) activity, whereas mTORC1 inhibition had no effect. Akt2 and mTORC2 gene silencing largely inhibited insulin-stimulated NBCe1 activity, whereas silencing of Akt1 and mTORC1 had no effect. Furthermore, insulin decreased sodium excretion, and this effect depended on phosphoinositide 3 kinase in vivo. Moreover, insulin reduced glucose production in rat proximal tubules and the expression of gluconeogenic genes in human and rat proximal tubules. Akt and mTORC1 inhibition largely abolished the observed insulin-mediated inhibitory effects. Gene silencing of insulin receptor substrate 1 (IRS1), Akt2, mTORC1, and mTORC2 also abolished insulin-mediated inhibition of gluconeogenesis. Additionally, in vivo, mTORC1 inhibition abolished insulin-mediated inhibitory effects in rat proximal tubules, although not in liver. These results indicate that insulin-stimulated proximal tubule sodium transport is mediated via the Akt2/mTORC2 pathway, whereas insulin-suppressed proximal tubule gluconeogenesis is mediated via the IRS1/Akt2/mTORC1/2 pathway. Thus, distinct pathways may play important roles in hypertension and hyperglycemia in metabolic syndrome and diabetes.

Impact of orthostatic hypotension on wheelchair use in patients with Parkinson's disease.

Wheelchair use is an important indicator of disease progression in Parkinson's disease (PD). Here, we investigated whether orthostatic hypotension (OH) affects the time to wheelchair use. We examined 33 PD patients with OH and 95 without OH. Median time to start using a wheelchair calculated from the time of disease onset was significantly shorter in patients with OH than in those without OH (12.0 vs 19.0 years; p < 0.001). Thus, appropriate management of OH and motor function is necessary.

Difference in cardiovascular response during orthostatic stress in Parkinson's disease and multiple system atrophy.

Although orthostatic hypotension is more prominent in multiple system atrophy (MSA) than in Parkinson's disease (PD), there is no study comparing the degree of decrease in total peripheral resistance and cardiac response during orthostatic stress between both diseases. In this study, we examined whether there is a difference in cardiovascular response between MSA and PD. We examined the results of the head-up tilt test in 68 patients with MSA, 28 patients with cardiac non-denervated PD, and 70 patients with cardiac denervated PD whose total peripheral resistance after 60° tilting was lower than the value at 0°. Differences in cardiac output and blood pressure changes were compared against the decrease in total peripheral resistance. There was no difference in the degree of decrease in total peripheral resistance among the three groups. However, the slope of the regression line revealed that the increase in cardiac output against the change in total peripheral resistance was significantly lower in the MSA group than in the cardiac non-denervated and denervated PD groups, and that the decrease in systolic blood pressure against the change in total peripheral resistance was significantly greater in the MSA group than in the cardiac non-denervated and denervated PD groups. In MSA, the cardiac response during orthostatic stress is lower than that in PD, possibly underlying the fact that orthostatic hypotension is more prominent in MSA than in PD.

Relationship between cardiac parasympathetic dysfunction and the anteroposterior diameter of the medulla oblongata in multiple system atrophy.

PURPOSE: Neurodegeneration of the nucleus ambiguus and the dorsal vagal motor nucleus has been implicated in cardiac parasympathetic dysfunction in multiple system atrophy (MSA). The nucleus ambiguus and the dorsal vagal motor nucleus, which are located in the medulla oblongata (MO), control the autonomic-specifically, the parasympathetic-functions of the body. The aim of our study was to investigate the relationship between cardiac parasympathetic dysfunction and the anteroposterior diameter of the MO in MSA by quantitatively analyzing magnetic resonance imaging (MRI) outcome measures. METHODS: We retrospectively assessed 40 consecutive patients with probable MSA and 25 age- and sex-matched controls. The anteroposterior diameter of the MO at two locations (MO diameter-A and -B) and the diameters of the midbrain and pons were measured by conventional MRI. A cardiac parasympathetic function score (CP-score) and cardiac sympathetic function score (CS-score) were generated by calculating the z-scores of multiple autonomic function tests. The relationship between the scores and the measured diameters of the brainstem was also investigated. RESULTS: The CP-score and CS-score were significantly lower in the patients with MSA than in the controls (CP-score: 0.61 ± 0.75 vs. - 0.38 ± 0.52, p < 0.001; CS-score: 0.91 ± 1.06 vs. - 0.57 ± 1.07, p < 0.001). Also, in the patients with MSA, the CP-score was significantly correlated with MO diameter-A (r = 0.40, p = 0.010), and the CS-score was significantly correlated with the diameter of the midbrain (r = 0.33, p = 0.038). CONCLUSION: The anteroposterior diameter of the MO is a potential imaging marker of parasympathetic dysfunction in MSA.

Development of anisotropic phantoms using wood and fiber materials for diffusion tensor imaging and diffusion kurtosis imaging.

OBJECTIVE: Several studies have demonstrated that anisotropic phantoms can be utilized for diffusion magnetic resonance imaging. The purpose of our study was to examine whether wood is suitable as an anisotropic phantom material from the viewpoints of affordability and availability. In the current study, wood was used for restricted diffusion, and fibers were used for hindered diffusion. MATERIALS AND METHODS: Wood and fiber phantoms were made. Diffusion kurtosis images were acquired with three magnetic resonance scanners. Fractional anisotropy, radial diffusivity, axial diffusivity, radial kurtosis and axial kurtosis values were measured. The wood phantom was imaged, and its durability was confirmed. The phantoms were imaged in varying orientations within the magnetic field. The wood was observed using an optical microscope. RESULTS: Ten kinds of wood and the fiber had a diffusion metrics. The wood diffusion metrics suggested low variation over a period of 9 months. Changing the orientation of the phantoms within the magnetic field resulted in changes in diffusion metrics. Observation of wood vessels and fibers was conducted. DISCUSSION: Wood and fibers have anisotropy and are promising as phantom materials. The development of anisotropic phantoms that anyone can use is useful for diffusion magnetic resonance imaging research and clinical applications.

Simultaneous multi-slice MR imaging of the hip at 3 T to reduce acquisition times and maintain image quality.

BACKGROUND: Newly developed simultaneous multi-slice (SMS) scans are now being introduced as a clinical application in neuroimaging. We examined the feasibility of SMS scans for joint imaging. The purpose of the present study was to prospectively compare the resolution and specific absorption rate (SAR) obtained using SMS to those of conventional methods in hip joint magnetic resonance imaging (MRI) and establish whether imaging times may be reduced using SMS in 3 T MRI and if image quality is affected. METHODS: Twenty-one patients (4 men and 17 women, average age, 51.5 years, range: 22 to 76 years) with hip pain underwent MR examinations of the unilateral hip joint. Three board-certified radiologists independently and blindly evaluated the images obtained with and without SMS using window and level settings and magnification according to personal preferences. Individual SAR values were measured for each protocol. A Wilcoxon signed-rank test and a t-statistic test were used for statistical analyses. Signal-to-noise ratio (SNR) was also compared using a phantom. RESULTS: SMS imaging maintained equivalent image quality to conventional imaging for evaluating the morphology of the hip joint, and also reduced imaging times by approximately 40%. SMS images had significantly higher SAR values than conventional images. The rate of difference (SMS/conventional) in SNR ranged between 80 and 111%. CONCLUSIONS: Based on its significantly lower acquisition times and the maintenance of similar image quality to conventional imaging, SMS may be applied to morphological evaluations of hip joint disorders without significantly increasing SAR.

Effect of Oral Alfacalcidol on Clinical Outcomes in Patients Without Secondary Hyperparathyroidism Receiving Maintenance Hemodialysis: The J-DAVID Randomized Clinical Trial.

Importance: Patients with chronic kidney disease have impaired vitamin D activation and elevated cardiovascular risk. Observational studies in patients treated with hemodialysis showed that the use of active vitamin D sterols was associated with lower risk of all-cause mortality, regardless of parathyroid hormone levels. Objective: To determine whether vitamin D receptor activators reduce cardiovascular events and mortality in patients without secondary hyperparathyroidism undergoing hemodialysis. Design, Setting, and Participants: Randomized, open-label, blinded end point multicenter study of 1289 patients in 207 dialysis centers in Japan. The study included 976 patients receiving maintenance hemodialysis with serum intact parathyroid hormone levels less than or equal to 180 pg/mL. The first and last participants were enrolled on August 18, 2008, and January 26, 2011, respectively. The final date of follow-up was April 4, 2015. Interventions: Treatment with 0.5 µg of oral alfacalcidol per day (intervention group; n = 495) vs treatment without vitamin D receptor activators (control group; n = 481). Main Outcomes and Measures: The primary outcome was a composite measure of fatal and nonfatal cardiovascular events, including myocardial infarctions, hospitalizations for congestive heart failure, stroke, aortic dissection/rupture, amputation of lower limb due to ischemia, and cardiac sudden death; coronary revascularization; and leg artery revascularization during 48 months of follow-up. The secondary outcome was all-cause death. Results: Among 976 patients who were randomized from 108 dialysis centers, 964 patients were included in the intention-to-treat analysis (median age, 65 years; 386 women [40.0%]), and 944 (97.9%) completed the trial. During follow-up (median, 4.0 years), the primary composite outcome of cardiovascular events occurred in 103 of 488 patients (21.1%) in the intervention group and 85 of 476 patients (17.9%) in the control group (absolute difference, 3.25% [95% CI, -1.75% to 8.24%]; hazard ratio, 1.25 [95% CI, 0.94-1.67]; P = .13). There was no significant difference in the secondary outcome of all-cause mortality between the groups (18.2% vs 16.8%, respectively; hazard ratio, 1.12 [95% CI, 0.83-1.52]; P = .46). Of the 488 participants in the intervention group, 199 (40.8%) experienced serious adverse events that were classified as cardiovascular, 64 (13.1%) experienced adverse events classified as infection, and 22 (4.5%) experienced malignancy-related serious adverse events. Of 476 participants in the control group, 191 (40.1%) experienced cardiovascular-related serious adverse events, 63 (13.2%) experienced infection-related serious adverse events, and 21 (4.4%) experienced malignancy-related adverse events. Conclusions and Relevance: Among patients without secondary hyperparathyroidism undergoing maintenance hemodialysis, oral alfacalcidol compared with usual care did not reduce the risk of a composite measure of select cardiovascular events. These findings do not support the use of vitamin D receptor activators for patients such as these. Trial Registration: UMIN-CTR Identifier: UMIN000001194.

[EVALUATIONS OF SENSORY ATTRIBUTE OF INTRANASAL CORTICOSTEROID SPRAYS IN HEALTHY VOLUNTEERS].

BACKGROUND: Intranasal corticosteroid sprays (INCSs) have not been a mainstay of the treatment for nasal allergies. We evaluated the sensory effects of INCSs since they might affect compliance to treatment. METHODS: The study population included 45 healthy volunteers. The subjects were randomized 1 : 1 to receive fluticasone furoate (FF) followed by mometasone furoate (MF) or MF followed by FF. There was a 30-minutes waiting period between the administration of each drug. The subjects completed questionnaire to evaluate the nasal sprays immediately after and 2 or 3 minutes after the drug administration. RESULTS: The subject favored FF over MF. A logistic regression analysis showed that nasal irritation was a significant effect after the use of FF and MF. The sensory effects of FF and MF were not unfavorable to the extent that they affect daily use. CONCLUSION: The sensory effects of INCSs were not as unfavorable as we thought.

Identification of three signaling molecules required for calcineurin-dependent monopolar growth induced by the DNA replication checkpoint in fission yeast.

Cell polarity is coordinately regulated with the cell cycle. Growth polarity of the fission yeast Schizosaccharomyces pombe transits from monopolar to bipolar during G2 phase, termed NETO (new end take off). Upon perturbation of DNA replication, the checkpoint kinase Cds1/CHK2 induces NETO delay through activation of Ca2+/calmodulin-dependent protein phosphatase calcineurin (CN). CN in turn regulates its downstream targets including the microtubule (MT) plus-end tracking CLIP170 homologue Tip1 and the Casein kinase 1γ Cki3. However, whether and which Ca2+ signaling molecules are involved in the NETO delay remains elusive. Here we show that 3 genes (trp1322, vcx1 and SPAC6c3.06c encoding TRP channel, antiporter and P-type ATPase, respectively) play vital roles in the NETO delay. Upon perturbation of DNA replication, these 3 genes are required for not only the NETO delay but also for the maintenance of cell viability. Trp1322 and Vcx1 act downstream of Cds1 and upstream of CN for the NETO delay, whereas SPAC6c3.06c acts downstream of CN. Consistently, Trp1322 and Vcx1, but not SPAC6c3.06c, are essential for activation of CN. Interestingly, we have found that elevated extracellular Ca2+ per se induces a NETO delay, which depends on CN and its downstream target genes. These findings imply that Ca2+-CN signaling plays a central role in cell polarity control by checkpoint activation.

Auxin signaling through SCFTIR1/AFBs mediates feedback regulation of IAA biosynthesis.

We previously reported that exogenous application of auxin to Arabidopsis seedlings resulted in downregulation of indole-3-acetic acid (IAA) biosynthesis genes in a feedback manner. In this study, we investigated the involvement of the SCFTIR1/AFB-mediated signaling pathway in feedback regulation of the indole-3-pyruvic acid-mediated auxin biosynthesis pathway in Arabidopsis. Application of PEO-IAA, an inhibitor of the IAA signal transduction pathway, to wild-type seedlings resulted in increased endogenous IAA levels in roots. Endogenous IAA levels in the auxin-signaling mutants axr2-1, axr3-3, and tir1-1afb1-1afb2-1afb3-1 also increased. Furthermore, YUCCA (YUC) gene expression was repressed in response to auxin treatment, and expression of YUC7 and YUC8 increased in response to PEO-IAA treatment. YUC genes were also induced in auxin-signaling mutants but repressed in TIR1-overexpression lines. These observations suggest that the endogenous IAA levels are regulated by auxin biosynthesis in a feedback manner, and the Aux/IAA and SCFTIR1/AFB-mediated auxin-signaling pathway regulates the expression of YUC genes.

Association between responsiveness to methoxy polyethylene glycol-epoetin beta and renal survival in patients with non-dialysis-dependent chronic kidney disease: A pooled analysis of individual patient-level data from clinical trials.

AIM: The association between responsiveness to continuous erythropoietin-receptor activator (CERA) and renal survival in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD) is uncertain. METHODS: We performed a pooled analysis of individual patient-level data drawn from five clinical trials involving CERA administration. Based on the responsiveness to CERA, patients were classified into poor- or good-response groups. Primary endpoints were defined as the initiation of dialysis or a 30% decrease in the estimated glomerular filtration rate (eGFR) from baseline. We set the landmark time point at 12 weeks after the start of CERA, from which we evaluated the time to the first renal event. The cumulative renal survival rates were calculated for each group using the Kaplan-Meier method. The adjusted hazard ratio was calculated using a stratified Cox regression model. RESULTS: Of 408 patients, 226 were analyzed. Haemoglobin levels and eGFRs were significantly lower in the poor-response group (n = 113) than in the good-response group (n = 113). Renal events occurred in 36.3% of the poor-response group and in 23.0% of the good-response group. The intergroup difference in renal survival rates was significant (log-rank test, P = 0.03) and the adjusted hazard ratio was 1.71 (95% confidence interval, 1.03-2.83), indicating an unfavorable outcome in the poor-response group. CONCLUSION: Hyporesponsiveness to CERA was associated with poor renal survival, consistent with the results of the conventional erythropoiesis-stimulating agent (ESA). It is recommended that a randomized controlled trial on CERA use be performed in patients with NDD-CKD with ESA-hyporesponsive anaemia.

Repair of a large pharyngocutaneous fistula with a free jejunal patch flap after salvage laryngectomy: A case report.

Preoperative chemoradiation therapy increases the risk of pharyngocutaneous fistula (PCF) after laryngectomy. In this report, we describe the use of a free jejunal patch flap and a deltopectoral flap for surgical treatment of a large PCF. A 52-year-old man underwent salvage laryngectomy and right neck dissection after concurrent radiotherapy for laryngeal carcinoma. On postoperative day 5, a pharyngeal fistula and neck abscess occurred with the right internal jugular vein thrombosis. We sutured the pharyngeal mucosa to the cervical skin to avoid carotid artery exposure, and we also ligated the right internal jugular vein. The PCF developed afterwards. The patient was being fed through a nasogastric tube and the fistula had increased in size. At the time of surgery, the external orifice became 5 cm × 5 cm in size. We performed the repair with a free jejunal patch flap and a deltopectoral flap. The harvested jejunum was opened along its antimesenteric border to design a sufficient free jejunal flap to cover the large PCF. A deltopectoral pedicled flap was used to reconstruct the neck skin defect to resurface the free jejunal patch flap. Both flaps survived. The patient could resume an oral diet 2 weeks after surgery. At 1 month after surgery, the skin pedicle of the deltopectoral flap was divided. There was no contracture or stricture 3 years after surgery and he maintained a regular diet. Reconstruction with a free jejunal patch flap and a deltopectoral flap may be a suitable method for repair of a large PCF. © 2014 Wiley Periodicals, Inc. Microsurgery 37:61-65, 2017.

Anatomic and Histological Study of Lingual Nerve and Its Clinical Implications.

Although the risk of injuring the lingual nerve in the mandibular molar area during dental treatment is high, it can be repaired by nerve grafting. However, from the perspective of clinical dentistry, the pathway and histomorphometric characteristics of this nerve remain to be documented in detail. The purpose of the present study was to morphologically elucidate the pathway of the lingual nerve to clarify its significance in a clinical setting. A histomorphometric analysis was also performed in consideration of nerve grafting. The vertical distance between the occlusal plane and the superior margin of the lingual nerve showed a gradual decrease from the premolar toward the distal molar area. This suggests that the risk of injuring the lingual nerve increases gradually toward the distal area. The average total fascicular area of the lingual nerve was 1.90 mm2, which was larger than that of the sural nerve. It is the first-choice donor nerve for grafting. Therefore, even though the total fascicular area of the donor nerve is a little smaller than that of the recipient nerve, nerve grafting should be successful.