Linear Probing of Molecules at Micrometric Distances from a Surface with Sub-Doppler Frequency Resolution.

We report on precision spectroscopy of subwavelength confined molecular gases. This was obtained by rovibrational selective reflection of NH_{3} and SF_{6} gases using a quantum cascade laser at λ≈10.6 µm. Our technique probes molecules at micrometric distances (≈λ/2π) from the window of a macroscopic cell with submegahertz resolution, allowing molecule-surface interaction spectroscopy. We exploit the linearity and high resolution of our technique to gain novel spectroscopic information on the SF_{6} greenhouse gas, useful for enriching molecular databases. The natural extension of our work to thin cells will allow compact frequency references and improved measurements of the Casimir-Polder interaction with molecules.

Dynamic compression of dense oxide (Gd3Ga5O12) from 0.4 to 2.6 TPa: Universal Hugoniot of fluid metals.

Materials at high pressures and temperatures are of great current interest for warm dense matter physics, planetary sciences, and inertial fusion energy research. Shock-compression equation-of-state data and optical reflectivities of the fluid dense oxide, Gd3Ga5O12 (GGG), were measured at extremely high pressures up to 2.6 TPa (26 Mbar) generated by high-power laser irradiation and magnetically-driven hypervelocity impacts. Above 0.75 TPa, the GGG Hugoniot data approach/reach a universal linear line of fluid metals, and the optical reflectivity most likely reaches a constant value indicating that GGG undergoes a crossover from fluid semiconductor to poor metal with minimum metallic conductivity (MMC). These results suggest that most fluid compounds, e.g., strong planetary oxides, reach a common state on the universal Hugoniot of fluid metals (UHFM) with MMC at sufficiently extreme pressures and temperatures. The systematic behaviors of warm dense fluid would be useful benchmarks for developing theoretical equation-of-state and transport models in the warm dense matter regime in determining computational predictions.

Reductions in tonic GABAergic current in substantia gelatinosa neurons and GABAA receptor δ subunit expression after chronic constriction injury of the sciatic nerve in mice.

BACKGROUND: Decreased Gamma-aminobutyric acid (GABA)-ergic phasic inhibitory transmission in the spinal cord is thought to be responsible for the development of neuropathic pain. However, the role of GABAergic tonic current in substantia gelatinosa (SG) neurons in neuropathic pain remains to be fully elucidated. In this study, we assessed GABAergic tonic currents of SG neurons in a sciatic nerve chronic constriction injury (CCI) mouse. METHOD: Whole-cell patch clamp recordings form lumbar spinal cord slices was performed to evaluate GABAergic currents. We also investigated the expression changes of GABAA receptor subunits which are considered to mediate tonic currents. RESULTS: The percentage of SG neurons receiving GABAergic tonic currents decreased in CCI mice compared with Naïve mice. No significant change was observed in the mean amplitude of GABAergic tonic currents. RT-PCR and Western blot revealed that the expression of GABAA receptor δ subunits decreased following CCI. CONCLUSION: A reduction in the expression the δ subunit of the GABAA receptor and diminished GABAergic tonic current in SG neurons were observed after CCI in mice. GABAergic tonic current plays a key role in neuropathic pain. The GABAA receptor δ subunit may be a therapeutic target in neuropathic pain. WHAT DOES THIS STUDY ADD?: In spinal SG neurons, GABAergic inhibitory transmission operates through both phasic and tonic currents, but physiological role is largely unknown. In this study, we report dysregulation of GABAA receptor δ subunit-mediated tonic current in SG neurons may result in spinal disinhibition resulting in neuropathic pain in CCI mice.

Characterization of mesenchymal progenitor cells in crown and root pulp from human mesiodentes.

OBJECTIVE: Mesiodentes are usually found in the central position of the upper or lower jaw as supernumerary teeth. Here, we obtained 10 mesiodentes and three permanent teeth (PT) and separated the dental pulp (DP) from these into crown and root portions. We then characterized and compared the isolated crown portion-derived cells (crown cells) with root portion-derived cells (root cells) using a range of in vitro assays. MATERIALS AND METHODS: Crown cells and root cells were examined for cell surface marker expression, colony-forming unit-fibroblast (CFU-F), cell proliferation, cell cycle characteristics and markers, and osteogenic and adipogenic differentiation. RESULTS: The proportion of CD105-positive cells (CD105(+) cells) in the crown cells vs the root cells varied among the mesiodentes, but not among the PT. When there were more CD105(+) cells in the root cells than in the crown cells, the root cells showed higher CFU-F, proliferation capacity, and osteogenic differentiation capacity. In contrast, when the crown cells contained more CD105(+) cells than the root cells, the crown cells showed the higher CFU-F, proliferation capacity, and osteogenic differentiation capacity. In addition, the sorted CD105(+) cells showed higher CFU-F and proliferation capacity than the sorted CD105(-) cells. CONCLUSION: These results indicated that proportion of CD105(+) cells is an effective means of characterizing DP-derived cells in mesiodentes.

Allele-specific genome editing and correction of disease-associated phenotypes in rats using the CRISPR-Cas platform.

The bacterial CRISPR/Cas system has proven to be an efficient gene-targeting tool in various organisms. Here we employ CRISPR/Cas for accurate and efficient genome editing in rats. The synthetic chimeric guide RNAs (gRNAs) discriminate a single-nucleotide polymorphism (SNP) difference in rat embryonic fibroblasts, allowing allele-specific genome editing of the dominant phenotype in (F344 × DA)F1 hybrid embryos. Interestingly, the targeted allele, initially assessed by the allele-specific gRNA, is repaired by an interallelic gene conversion between homologous chromosomes. Using single-stranded oligodeoxynucleotides, we recover three recessive phenotypes: the albino phenotype by SNP exchange; the non-agouti phenotype by integration of a 19-bp DNA fragment; and the hooded phenotype by eliminating a 7,098-bp insertional DNA fragment, evolutionary-derived from an endogenous retrovirus. Successful in vivo application of the CRISPR/Cas system confirms its importance as a genetic engineering tool for creating animal models of human diseases and its potential use in gene therapy.

Milrinone, a phosphodiesterase III inhibitor, prevents reduction of jugular bulb saturation during rewarming from hypothermic cardiopulmonary bypass.

INTRODUCTION: Inadequate cerebral oxygen balance during cardiopulmonary bypass may cause neuropsychological dysfunction. Milrinone, a phosphodiesterase III inhibitor, augments cerebral blood flow by direct vasodilatation. We conducted a prospective, randomized study in patients undergoing cardiac surgery with cardiopulmonary bypass to clarify the clinical efficacy of milrinone in the imbalance of cerebral oxygen supply and demand during the rewarming period of cardiopulmonary bypass. METHODS: This is a prospective, randomized and placebo-controlled study. After anesthesia, a 5.5 F fiberoptic oximeter catheter was inserted into the right jugular bulb retrogradely for monitoring the jugular venous oxyhemoglobin saturation (SjO(2)). Patients were randomly assigned to two groups, one receiving a continuous infusion of milrinone, 0.5 µg/kg/min during hypothermic cardiopulmonary bypass, and the other receiving saline as control. RESULTS: Milrinone significantly prevented the reduction of the jugular venous oxyhemoglobin saturation at 10 minutes from the start of rewarming compared with the control group, but did not do so from 10 to 20 minutes after rewarming. CONCLUSION: Milrinone suppresses the reduction of SjO(2) and improves the balance of cerebral oxygen supply and demand during the early rewarming period of hypothermic cardiopulmonary bypass.

Small temperature variations alter edaravone-induced neuroprotection of cortical cultures exposed to prolonged hypoxic episodes.

BACKGROUND: Edaravone, a free radical scavenger, has been shown to be neuroprotective in vivo and in vitro. However, the impact of small temperature variations on its neuroprotective actions remains unknown. METHODS: We examined the degree of neuroprotection conferred by various concentrations of edaravone on cortical cultures exposed to prolonged hypoxia (24 h) under three conditions: mild hypothermia (32 degrees C), normothermia (37 degrees C), and mild hyperthermia (39 degrees C). The survival of cortical neurones from E16 Wistar rats (SR) was evaluated using photomicrographs taken before and after exposure to hypoxia. RESULTS: The mean survival of neurones exposed to hypoxia at normothermia was 14.7 (sem 1.8)%. The addition of 50 microM edaravone significantly improved the mean survival to 40.5 (4.7)%. This improvement was noted at higher doses of edaravone (5 microM < or =) but not at lower doses (< or =500 nM). With mild hypothermia and prolonged hypoxia without edaravone, neuroprotection was significantly improved with a mean survival of 63.0 (5.2)%. This neuroprotective effect was not enhanced with the addition of edaravone, even at the highest dose. Hypoxia-induced neurotoxicity was aggravated by mild hyperthermia as reflected by a mean survival of 9.1 (2.1)%. However, higher concentrations of edaravone inhibited the deleterious effect of mild hyperthermia, thereby demonstrating a significant neuroprotective effect. The survival of neurones subjected to both hyperthermia and edaravone was the same as that of neurones exposed to normothermia and edaravone. CONCLUSIONS: Temperature is a potential factor in determining whether edaravone confers a neuroprotective effect when applied during prolonged hypoxic insults.

Prolonged hoarseness and arytenoid cartilage dislocation after tracheal intubation.

BACKGROUND: Hoarseness is a common complication after tracheal intubation and prolonged hoarseness may be very limiting for a patient. This study was designed to examine the duration of hoarseness after tracheal intubation and to identify risk factors that may increase the duration of hoarseness. METHODS: We prospectively studied 3093 adult patients (aged 18-77 yr), over a 3 yr period who required tracheal intubation. Postoperative hoarseness was assessed on the day of operation and on postoperative days 1, 3, and 7 by standardized interview by the resident anaesthetist managing the patient. If postoperative hoarseness was still present on postoperative day 7, the patient was followed up until complete resolution. We evaluated age, gender, weight, Cormack grades, duration of intubation, and the anaesthetic agents used as factors affecting the duration of hoarseness after tracheal intubation. RESULTS: Hoarseness was observed in 49% of patients on the day of surgery and in 29%, 11%, and 0.8% on 1, 3, and 7 postoperative days, respectively. Multiple regression analysis showed that patient age and duration of intubation, but not gender, weight, Cormack grades, or the agents used, were significant predictors of increased duration of hoarseness after tracheal intubation. We found three patients with arytenoid cartilage dislocation (0.097%) in our study population. CONCLUSIONS: The age of the patient and duration of intubation were significant factors in the duration of hoarseness after tracheal intubation. In addition, the incidence of arytenoid cartilage dislocation was 0.097%.

Innate resistance to flavivirus infections and the functions of 2'-5' oligoadenylate synthetases.

Mouse susceptibility to experimental infections with flaviviruses is significantly influenced by a cluster of genes on chromosome 5 encoding a family of proteins with enzymatic properties, the 2'-5' oligoadenylate synthetases (OAS). Positional cloning of the locus in question has revealed that susceptibility of laboratory inbred strains to this class of virus is associated with a nonsense mutation in the gene encoding the OAS1B isoform. Analysis of the molecular structure of the cluster in different mammalian species including human indicates that the cluster is extremely polymorphic with a highly variable number of genes and pseudogenes whose functions are not yet completely established. Although still preliminary, a few recent observations also substantiate a possible role for OAS1 in human susceptibility to viral infections (West Nile virus, SARS, etc.) and its possible involvement in some other diseases such as type 1 diabetes and multiple sclerosis. Finally, convergent observations indicate that the molecules encoded by the 2 '-5' OAS cluster might be involved in other fundamental cellular functions such as cell growth and differentiation, gene regulation, and apoptosis.

Correlation between plasma milrinone concentration and renal function in patients with cardiac disease.

BACKGROUND: The dose of milrinone should be reduced in patients with renal failure. However, there is little data examining the relationship between plasma concentration of milrinone (pCmil) and renal function in intravenous infusion. METHODS: We evaluated the pCmil relative to renal function during intravenous infusion. We enrolled 10 heart failure patients. Milrinone was continuously infused at a rate of 0.2 microg/kg/min. Blood samples were collected at 6, 12, 24, and 48 h after the beginning of infusion. Urine was sampled during the first 24 h to calculate creatinine clearance (CLcr) and renal clearance of milrinone (rCLmil). RESULTS: The pCmil exhibited stability over 6 h after the beginning of infusion. During the first 24 h, CLcr and rCLmil were 62.2+/-30.6 ml/min and 1.67+/-0.77 ml/kg/min (106.2+/-60.3 ml/min), respectively. The rCLmil was highly correlated with CLcr. Y=1.77X-3.89 (X, CLcr; Y, rCLmil; R(2)=0.809, P<0.0001). Significant correlations were observed between CLcr and the plasma concentration during the continuous infusion. This correlation was expressed as the equation Y=51.1 x (BW/X)+28.2 (X; CLcr, Y; plasma concentration; BW, body weight; R(2)=0.695, P<0.01). CONCLUSION: The pCmil exhibited stability 6 h or later after the continuous infusion of milrinone 0.2 microg/kg/min. The pCmil can be estimated by the value of CLcr and BW.

Mirror visual feedback alleviates deafferentation pain, depending on qualitative aspects of the pain: a preliminary report.

OBJECTIVES: Following lesions in somatosensory pathways, deafferentation pain often occurs. Patients report that the pain is qualitatively complex, and its treatment can be difficult. Mirror visual feedback (MVF) treatment can improve deafferentation pain. We sought to classify the qualities of the pain in order to examine whether the potential analgesic effect of MVF depends on these qualities. METHODS: Twenty-two patients with phantom limb pain, or pain related to spinal cord or nerve injury, performed a single MVF procedure. Before and after the MVF procedure, we evaluated phantom limb awareness, movement representation of the phantom or affected/paralysed limb, pain intensity on an 11-point numerical rating scale (0-10) and the qualities of the pain [skin surface-mediated (superficial pain) vs deep tissue-mediated (deep pain)] using lists of pain descriptors for each of the two categories. RESULTS: Fifteen of the patients perceived the willed visuomotor imagery of the phantom or affected/paralysed limb after the MVF procedure. In most of the patients, a reduction in pain intensity and a decrease in the reporting of deep-pain descriptors were linked to the emergence of willed visuomotor imagery. CONCLUSIONS: In this pilot study, we roughly classified the pain descriptor items into two types for evaluating the qualities of deafferentation pain. We found that visually induced motor imagery by MVF was more effective for reducing deep pain than superficial pain. This suggests that the analgesic effect of MVF treatment does depend on the qualities of the pain. Further research will be required to confirm that this effect is a specific consequence of MVF.

The antiarrhythmic effect of centrally administered rilmenidine involves muscarinic receptors, protein kinase C and mitochondrial signalling pathways.

BACKGROUND AND PURPOSE: We have previously demonstrated that stimulation of imidazoline receptors in the CNS prevented halothane-adrenaline arrhythmias during halothane anaesthesia and that stimulation of the vagus nerve may be critical to this effect. However, details of the mechanism(s) involved are not yet available. The present study was designed to examine the role of muscarinic receptors, protein kinase C (PKC), ATP-sensitive potassium channels (K(ATP)) and the mitochondrial permeability transition pore (MPTP) in the antiarrhythmic effect of rilmenidine, an imidazoline receptor agonist. EXPERIMENTAL APPROACH: Rats were anaesthetized with halothane and monitored continuously for arterial blood pressure and premature ventricular contractions. The arrhythmogenic dose of adrenaline was defined as the lowest dose producing three or more premature ventricular contractions within a 15-s period. We confirmed that centrally administered rilmenidine prevented halothane-adrenaline arrhythmias and then examined the antiarrhythmic effect of rilmenidine in the presence of atropine methylnitrate, a muscarinic receptor antagonist, calphostin C, a PKC inhibitor, HMR-1098, a sarcolemmal K(ATP) inhibitor, 5-hydroxydecanoic acid, a mitochondrial K(ATP) inhibitor or atractyloside, an MPTP opener. KEY RESULTS: The antiarrhythmic effect of rilmenidine was significantly inhibited by atropine methylnitrate, calphostin C, 5-hydroxydecanoic acid and atractyloside, but the effects of HMR-1098 in our model were not clear. CONCLUSIONS AND IMPLICATIONS: The present results suggest that muscarinic receptors, PKC, mitochondrial K(ATP) channels and MPTP may be crucial components of the mechanism involved in the antiarrhythmic effect of rilmenidine given into the CNS.

Arytenoid dislocation after cardiac surgery.

Occurring most usually as complications of upper aerodigestive tract instrumentation during endotracheal intubation or extubation, arytenoid cartilage dislocation and arytenoid subluxation are uncommon laryngeal injuries. Their precise cause, however, is usually difficult to determine. We encountered arytenoid dislocation following cardiac surgery requiring the use of transesophageal echocardiography (TEE). This case prompted us to review some of the mechanisms of injury to the cricoarytenoid joint. We conclude that even very subtle force may dislocate the arytenoid cartilage. We speculate that careless insertion of a TEE probe is mechanically capable of causing arytenoid dislocation and arytenoid subluxation. As ideal tools for intra-operative cardiovascular monitoring, TEE probes are increasingly being used routinely during cardiovascular surgery. So far, arytenoid cartilage dislocation and subluxation following TEE probe insertion have been reported rarely, but complications caused by TEE may increase in the near future. We wish to emphasize the pathophysiological risks of TEE monitoring and other procedures associated with anesthesia, and the need for a proper explanation to achieve informed consent before carrying out TEE monitoring during cardiac surgeries.

Prism adaptation to optical deviation alleviates pathologic pain.

BACKGROUND: The human visual and somatosensory systems are interdependent. Using a visual subjective body-midline (SM) judgment task, we previously confirmed that pathologic pain and deafferentation can modify visuospatial perception, indicating that altered somatosensory experience can modify visual perception. Conversely, in the present study we investigated whether a change in visual experience can modify perception of pathologic pain. METHODS: We used prism adaptation (PA) to modify subjects' visual experience. Five patients with complex regional pain syndrome (CRPS) adapted to wedge prisms, producing a 20-degree visual displacement toward the unaffected side. Further, we used several types of prisms in a longitudinal single-case study. Wearing prismatic goggles, the subjects performed a target-pointing task once a day for 2 weeks. We evaluated pain intensity and visual SM judgment to measure the adaptive aftereffects at three time points: before PA (pre-test), immediately after the first PA exposure (IA-test), and after a 14-day sequence of PA exposure (post-test). RESULTS: PA toward the unaffected side alleviated pathologic pain and other CRPS pathologic features, when measured at post-test. None of the IA-test results showed an analgesic effect. In the longitudinal study, sham PA and 5-degree PA did not produce any effects, and PA toward the affected side actually exacerbated the subjective pain. CONCLUSIONS: Our findings suggest that vision can influence pathologic pain, and preliminarily suggest that prism adaptation has a direction-specific and reproducible effect on not only pathologic pain but also other CRPS pathologic features. Thus, prism adaptation may be a viable cognitive treatment for CRPS.

Pathologic pain distorts visuospatial perception.

Spatial perception is achieved by integrating multisensory information. Using visual subjective body midline (vSM) judgments in patients with unilateral limb pain (complex regional pain syndrome [CRPS]), we found that their vSM deviated toward the affected side; however, deafferentation of the affected limb caused a transient pain decrease and a transient shift of the vSM deviation toward the unaffected side. Our results indicate that the persistent pain state in CRPS distorts visuospatial perception.

Ketamine and thiopental sodium: individual and combined neuroprotective effects on cortical cultures exposed to NMDA or nitric oxide.

BACKGROUND: An N-methyl-D-aspartate (NMDA) blocker, ketamine, has been shown to be neuroprotective both in vivo and in vitro. However, ketamine is not commonly recommended for use in patients suffering from cerebral ischaemia because of its adverse neurological effects. We hypothesized that combined administration of ketamine and thiopental sodium (TPS) would be highly effective in protecting cerebral cortical neurones from ischaemia, with possibly reduced dosages. METHODS: We examined the degree of neuroprotection provided by various concentrations of ketamine and TPS, alone and in combination, in cortical cultures exposed to NMDA or a nitric oxide-releasing compound (NOC-5) for 24 h. The survival rate (SR) of E16 Wistar rat cortical neurones was evaluated using photomicrographs before and after exposure to these compounds. RESULTS: The SRs of cortical neurones exposed to 30 microM NMDA or NOC-5 were 15.0 (3.8)%, 12.8 (3.1)%, respectively. Higher doses (5, 10 and 50 microM) but not lower doses (<1 microM) of ketamine improved SRs [57.9 (2.2)%, 61.1 (5.4)%, 76.7 (3.0)%, respectively] against NMDA but not NOC. Enhanced survival was observed with combined administration of 5 or 10 microM ketamine and 50 microM TPS [SR 71.3 (4.8)%, 74.7 (3.7)%, respectively, P<0.05 if ketamine alone, P<0.01 if TPS alone], against NMDA-induced neurotoxicity in vitro. Only the highest dose of TPS (50 microM) improved survival after NOC exposure. This neuroprotection was not influenced by ketamine. CONCLUSIONS: These data indicate that a low, clinically relevant dose of ketamine offer significant neuroprotection during prolonged exposure to NMDA but not to NOC. Combinations of reduced doses of ketamine and TPS exhibited enhanced neuroprotection against NMDA-induced neurotoxicity. Hence, combinations of these two common i.v. anaesthetics agents could be developed to protect the brain from ischaemia.

Noxious cold stimulation induces mitogen-activated protein kinase activation in transient receptor potential (TRP) channels TRPA1- and TRPM8-containing small sensory neurons.

Two cold-sensitive transient receptor potential (TRP) channels, TRPA1 and TRPM8, have been identified and considered interesting because of their possible roles in thermosensation, nociception and other functions. Recently, we have reported that the phosphorylation of extracellular signal-regulated protein kinase and p38 mitogen-activated protein kinase occurred in primary afferent neurons in response to noxious heat stimulation of the peripheral tissue, i.e. activity-dependent activation of extracellular signal-regulated protein kinase and p38 in dorsal root ganglion neurons. In the present study, we investigated the phosphorylation of extracellular signal-regulated protein kinase, p38, and c-Jun N-terminal kinase in the rat dorsal root ganglion by cold stimulation using immunohistochemistry. Cold stimuli (28-4 degrees C) were applied by immersion of the hind paw into a water bath (six times of 10 s stimulation and 10 s interval, total 2 min). Noxious cold stimulation induced phosphorylated-extracellular signal-regulated protein kinase and phosphorylated-p38, but not phosphorylated-c-Jun N-terminal kinase, in small to medium diameter sensory neurons with a peak at 2 min after stimulation. We found that a cold stimulation at 4 degrees C showed a marked increase in the number of activated neurons. Furthermore, double staining for phosphorylated-extracellular signal-regulated protein kinase and phosphorylated-p38 showed no colocalization in the dorsal root ganglion neurons. We then performed double-labeling experiments for TRPA1 and TRPM8 mRNA and phosphorylation of mitogen-activated protein kinase. The majority of phosphorylated-extracellular signal-regulated protein kinase-positive neurons also expressed TRPM8 mRNA, whereas phosphorylated-p38 heavily colocalized with TRPA1 mRNA after noxious cold stimulation. Our data suggest that the noxious, but not innocuous, cold stimulation in vivo induced differential activation of extracellular signal-regulated protein kinase and p38 pathways in each subpopulation containing TRPA1 or TRPM8 in dorsal root ganglion.

Transition to a virtually incompressible oxide phase at a shock pressure of 120 GPa (1.2 Mbar): Gd3Ga5O12.

Cubic, single-crystal, transparent Gd(3)Ga(5)O(12) has a density of 7.10 g/cm(3), a Hugoniot elastic limit of 30 GPa, and undergoes a continuous phase transition from 65 GPa to a quasi-incompressible (QI) phase at 120 GPa. Only diamond has a larger Hugoniot elastic limit. The QI phase of is more incompressible than diamond from 170 to 260 GPa. Electrical conductivity measurements indicate the QI phase has a band gap of 3.1 eV. Gd(3)Ga(5)O(12) can be used to obtain substantially higher pressures and lower temperatures in metallic fluid hydrogen than was achieved previously by shock reverberation between Al(2)O(3) disks.

Primary motor cortex stimulation within the central sulcus for treating deafferentation pain.

Nine patients with post-stroke pain, six with brachial plexus injuries, two with phantom limb pain, one with spinal cord injury, and one with brain stem injury were treated with a modified motor cortex stimulation (MCS) protocol. Preoperative pharmacological tests were performed with phentolamine, lidocaine, ketamine, thiopental, morphine, and placebo. We placed a grid electrode in the subdural space to decide upon the best stimulation point for pain relief over a few weeks with the purpose of determining the placement of a Resume electrode. In five patients, Resumes were implanted in the interhemispheric fissure to reduce lower extremity pain. In five other patients, Resumes were placed within the central sulcus to stimulate area 4 and area 3b. In addition, electrodes were also placed on the surface of the precentral gyrus. Fourteen of the 19 patients showed pain reduction (6 excellent, 3 good, and 5 fair) using the MCS with our results indicating area 4 within the central sulcus to be the optimal stimulation point for pain relief. We speculate that conventional method may sometimes fail to stimulate area 4 and that focal stimulation of the primary motor cortex within the central sulcus may improve the efficacy of this treatment. Our pharmacological tests show that patients with ketamine sensitivity seem to be good candidates for MCS. Test stimulation with a subdural multi-grid electrode and Resumes in the cetral sulcus were helpful in locating the best stimulation point for pain relief.