Barthel Index Score Predicts Mortality in Elderly Heart Failure　- A Goal of Comprehensive Cardiac Rehabilitation.

BACKGROUND: A strategy to predict mortality in elderly heart failure (HF) patients has not been established.Methods and Results:We retrospectively enrolled 413 HF patients aged ≥65 years (mean age 78 years) who had received comprehensive cardiac rehabilitation (CR) during hospitalization. Basic activities of daily life were assessed before discharge using the Barthel index (BI). Of 413 HF patients, 116 (28%) died during a median follow-up period of 1.90 years (interquartile range 1.20-3.23 years). An adjusted dose-dependent association analysis showed that the hazard ratio (HR) of mortality increased in an almost linear manner as the BI score decreased, and that a BI score of 85 corresponded to an HR of 1.0. Kaplan-Meier survival curves showed that the survival rate was lower for patients with a low BI (<85) than for those with a high BI (≥85; 65% vs. 74%, respectively; P=0.007). In multivariate Cox regression analyses, low BI was independently associated with higher mortality after adjusting for predictors, including B-type natriuretic peptide. Inclusion of the BI into the adjusted model improved the accuracy of the prediction of mortality. CONCLUSIONS: A BI score <85 at the time of discharge is associated with increased mortality independent of known prognostic markers, and achieving functional status with a BI score ≥85 by comprehensive CR during hospitalization may contribute to favorable outcomes in elderly HF patients.

Nutritional Status and Energy Intake as Predictors of Functional Status After Cardiac Rehabilitation in Elderly Inpatients With Heart Failure　- A Retrospective Cohort Study.

BACKGROUND: Whether the short-term effect of cardiac rehabilitation (CR) in elderly patients with heart failure (HF) is influenced by nutritional status is uncertain, so the present study investigated the effect of nutritional status on functional recovery after CR in elderly HF inpatients.Methods and Results:We enrolled 145 patients admitted for treatment of HF who were aged ≥65 years and had a low functional status defined as a Barthel index (BI) score ≤85 points at the commencement of CR. Nutritional status was assessed by the Mini Nutritional Assessment Short Form (MNA-SF) and total energy intake per day. The primary endpoint was functional status determined by the BI score at discharge. The median CR period was 20 days (interquartile range: 14-34 days), and 87 patients (60%) were functionally dependent (BI score ≤85) at discharge. Multivariate logistic regression analysis showed that MNA-SF score (odds ratio [OR]: 0.76, P=0.02) and total energy intake at the commencement of CR (OR: 0.91, P=0.02) were independent predictors of functional dependence after CR. MNA-SF score ≤7 and total energy intake ≤24.5 kcal/kg/day predicted functional dependence at discharge with moderate sensitivity and specificity. CONCLUSIONS: MNA-SF score and total energy intake at the commencement of CR are novel predictors of the extent of functional recovery of elderly HF inpatients after in-hospital CR.

Daily physical activity affects exercise capacity in patients with idiopathic pulmonary fibrosis.

[Purpose] The aim of this study was to determine which factors, including pulmonary, physical, and mental functions; dyspnea; and daily physical activity (PA) affect the 6-minute walk distance (6MWD) in IPF patients. [Subjects and Methods] The pulmonary, physical, and mental functions; dyspnea; PA; and 6MWD were assessed in 38 outpatients with IPF. PA was represented by the mean number of steps per day. [Results] The mean 6MWD was 443.8 m (SD, 98.5), and the mean number of steps per day showing PA was 5148.4 (SD, 3295.7). The 6MWD was correlated with age, base dyspnea index, vital capacity (VC), diffusion capacity of carbon monoxide, quadriceps force (QF), dyspnea during the 6-minute walk test, and PA. Stepwise multiple regression analysis revealed that VC (ß=0.382), QF (ß=0.272), and PA (ß=0.574) were contributing factors of the 6MWD. [Conclusion] In patients with IPF, PA has a greater effect on the 6MWD than VC and QF. The evaluation of daily PA, in addition to physiological and muscle functions, is important in patients with IPF.

Factors affecting dyspnea after the 6-minute walk test in idiopathic pulmonary fibrosis patients presenting with exercise-induced hypoxemia.

[Purpose] The current study aimed to investigate factors affecting dyspnea after the 6-minute walk test (6MWT) in idiopathic pulmonary fibrosis (IPF) patients presenting with hypoxemia. [Subjects and Methods] The subjects were IPF out-patients with stable symptoms whose percutaneous arterial oxygen saturation fell to 88% during the 6MWT test. Quadriceps force, 6-minute walk distance (6MWD), dyspnea after the 6MWT, and leg fatigue (LF) were evaluated as exercise-related variables. [Results] The subjects were 14 patients (mean age 73.6 ± 6.3 years) classed based on the modified Medical Research Council dyspnea scale as 0 for 2 patients, 1 for 6 patients, and 2 for 6 patients, indicating that the patients were comparatively mild cases. Mean 6MWD was 408.9 ± 102.4 m, and dyspnea after the 6MWT and LF were 3.0 ± 1.4 and 1.5 ± 1.5, respectively. Dyspnea after the 6MWT was correlated with vital capacity (VC), forced vital capacity, and LF. Stepwise multiple regression analysis identified VC and LF as factors significantly affecting dyspnea after the 6MWT. [Conclusion] The results of this study demonstrated that it is necessary to evaluate both pulmonary function and LF in IPF patients presenting with exercise-induced hypoxemia and exertional dyspnea.

[Unilteral Spatial Neglect: Clinical Manifestations and Neural Correlates].

Unilateral spatial neglect is the failure of brain-damaged patients to report, respond, or orient to novel or meaningful stimuli presented to the contralateral side of the lesion. This usually involves the right cerebral hemisphere. Neglect presents with no restriction in gaze direction and results in difficulty across various aspects of daily activities, distinguishing it from simple homonymous hemianopia. The basic mechanisms underlying neglect is rightward bias of spatial attention, while non-direction-specific cognitive problems may contribute to clinical expressions of neglect.

Full-field input generated from right visual field information for healthy participants reproduces performance simulating left unilateral spatial neglect in line bisection.

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre when bisecting a horizontal line. This pathological phenomenon may be explained as a result of greater dependence on the right endpoint in the external reference frame (Koyama et al., Brain Cogn, 35, 1997, 271; McIntosh et al., Cogn Brain Res, 25, 2005, 833). Ishiai et al. (Brain, 112, 1989, 1485) reported that once patients with USN fixated on a certain point on the right part of the presented line, they persisted with this point and marked the subjective midpoint there without leftward searches. Ishiai et al.'s interpretation was that the patients saw a totalised line representation that extended equidistantly to the right and left sides, based on the information of the attended rightward extent from the subjective midpoint. Accordingly, we used virtual reality goggles (VRG) and devised a mirror-image viewing (MV) condition that showed a full-field view based on the right visual field information to test whether healthy participants would thereby show neglect-like bisection performance. The participants were 30 healthy adults (22-37 years old; 15 women and 15 men). In this condition, 96.7% (29/30) of participants were judged to exhibit USN-like performance of line bisection, indicating the effectiveness of MV condition to simulate USN. The novelty of the present study lies in the use of a task-specific intervention of neglect-like visuospatial processing during line bisection without attempting to modify the direction of spatial attention. This approach may contribute to the understanding of the pathological visuospatial processing of USN.

Functional outcome of a patient after hip disarticulation due to an infection 10 years after limb salvage surgery for osteosarcoma: A case report.

Limb salvage is a common procedure after extensive osteosarcoma resection. However, the long-term outcomes after limb salvage surgery (LSS) remain unclear. In this article, the case of a 24-year-old man who underwent hip disarticulation (HD) after an uncontrollable infection is presented. He was previously diagnosed with right distal femoral osteosarcoma and underwent LSS 10 years before disarticulation. Four years after LSS, an uncontrollable infection developed around the endoprosthesis, which eventually prompted HD. The Musculoskeletal Tumor Society (MSTS) functional rating system and the Toronto Extremity Salvage Score were used to compare the subject's activity statuses after LSS and HD. MSTS functional scores were 53.3% after LSS and 60% after HD. Toronto Extremity Salvage Scores were 78.3% after LSS and 95.8% after HD. The subject's emotional acceptance was 3 for LSS and 5 for HD (0 = worst and 5 = best). Both the MSTS and Toronto Extremity Salvage Scores were greater after HD than after LSS. The subject's improved emotional acceptance of the affected limb after HD contributed to the improved functional assessment scores. Alleviation of pain and other disabilities associated with the infection may have contributed to the higher functional scores after the more recent HD surgery. Even if amputation is unavoidable because of complications, high psychological acceptance may prevent a decrease in patient mobility and quality of life after amputation.

Prediction of Early Postoperative Language Function by Quantitative Evaluation with Visual and Auditory Naming Tasks during Awake Craniotomy for Brain Tumor Resection: Significance of Auditory Naming Task.

Language tasks for monitoring intraoperative language symptoms have not yet been established. This study aimed to examine whether the quantitative evaluation of language function with visual and auditory naming during awake craniotomy predicts early postoperative language function in patients. Thirty-seven patients with brain tumors in the language-dominant hemisphere were included. They underwent visual and auditory naming preoperatively and at the end of tumor resection for intraoperative evaluation. Using the Western Aphasia Battery, their overall language functions were evaluated preoperatively, early postoperatively (within 1 week), and late postoperatively (after 1 month). The preoperative and intraoperative changes in the visual and auditory naming scores were significantly correlated with most of the Western Aphasia Battery score changes between the preoperative and early postoperative evaluations, which was more remarkable for auditory naming. Multiple linear regression analysis showed that changes in the auditory naming score predicted the preoperative to early postoperative changes in the aphasia quotient of the Western Aphasia Battery. Receiver operating characteristics analysis showed a higher area under the curve or discriminative power for auditory than visual naming in predicting the development or exacerbation of aphasia in the early postoperative period. Considering the analyses applied separately for low- and high-grade glioma, auditory naming, which taps into a wider range of linguistic functions, may be more informative than visual naming as language evaluation in awake craniotomy for the early postoperative development of aphasia, especially for patients with high-grade glioma.

Intravenous administration of auto serum-expanded autologous mesenchymal stem cells in stroke.

Transplantation of human mesenchymal stem cells has been shown to reduce infarct size and improve functional outcome in animal models of stroke. Here, we report a study designed to assess feasibility and safety of transplantation of autologous human mesenchymal stem cells expanded in autologous human serum in stroke patients. We report an unblinded study on 12 patients with ischaemic grey matter, white matter and mixed lesions, in contrast to a prior study on autologous mesenchymal stem cells expanded in foetal calf serum that focused on grey matter lesions. Cells cultured in human serum expanded more rapidly than in foetal calf serum, reducing cell preparation time and risk of transmissible disorders such as bovine spongiform encephalomyelitis. Autologous mesenchymal stem cells were delivered intravenously 36-133 days post-stroke. All patients had magnetic resonance angiography to identify vascular lesions, and magnetic resonance imaging prior to cell infusion and at intervals up to 1 year after. Magnetic resonance perfusion-imaging and 3D-tractography were carried out in some patients. Neurological status was scored using the National Institutes of Health Stroke Scale and modified Rankin scores. We did not observe any central nervous system tumours, abnormal cell growths or neurological deterioration, and there was no evidence for venous thromboembolism, systemic malignancy or systemic infection in any of the patients following stem cell infusion. The median daily rate of National Institutes of Health Stroke Scale change was 0.36 during the first week post-infusion, compared with a median daily rate of change of 0.04 from the first day of testing to immediately before infusion. Daily rates of change in National Institutes of Health Stroke Scale scores during longer post-infusion intervals that more closely matched the interval between initial scoring and cell infusion also showed an increase following cell infusion. Mean lesion volume as assessed by magnetic resonance imaging was reduced by >20% at 1 week post-cell infusion. While we would emphasize that the current study was unblinded, did not assess overall function or relative functional importance of different types of deficits, and does not exclude placebo effects or a contribution of recovery as a result of the natural history of stroke, our observations provide evidence supporting the feasibility and safety of delivery of a relatively large dose of autologous mesenchymal human stem cells, cultured in autologous human serum, into human subjects with stroke and support the need for additional blinded, placebo-controlled studies on autologous mesenchymal human stem cell infusion in stroke.

Mental representation of a line when patients with left unilateral spatial neglect bisect it: A study with an endpoint reproduction task.

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre. Based on the previous findings (e.g., Ishiai et al. 1989, Brain, 112, 1485), we hypothesized that the patients with left USN may see the representational image of a line that extends equally towards either side of the subjective midpoint depending not upon the information about the leftward extent. The present study tested whether patients with left USN would place the subjective midpoint at the centre of their mental representation of the line. The participants were 10 patients with left USN and 10 neurologically healthy controls. We devised a new 'endpoint reproduction task' using a computer display with a touch panel to seek the representational image when patients with left USN bisect lines and asked the participants to reproduce the location of the right or left endpoint after bisecting lines. The results showed that the representational image of the bisected line depends primarily on the location of the objective right endpoint, not on the location of the objective left endpoint in space. The analyses of the estimated right and left representational extents confirmed our hypotheses that patients with left USN would bisect a line seeing the representational line image that centred across their subjective midpoint. We believe that the findings of the present study with the use of the endpoint reproduction task will contribute to a better understanding of the visuospatial process underlying line bisection of patients with left USN.

Endpoints and viewpoints on spatial neglect.

In this issue of the Journal of Neuropsychology, Abe and Ishiai (2022) report an experiment designed to probe the subjective experience of line bisection in neglect. A re-analysis of their data can also offer insights into how best to characterise neglect performance for this and other tasks. We show that sensitive measures of neglect can be obtained by quantifying the difference in the influence (or 'weighting') that each endpoint has on the response. The right endpoint is dramatically more influential than the left in people with neglect performing line bisection and endpoint reproduction tasks. This supports the view that neglect may limit the ability to simultaneously represent two locations, so that the response is determined primarily with respect to the right endpoint. We also discuss Abe and Ishiai's conclusion that bisection responses in neglect are accompanied by the subjective experience of a complete line extending equally to either side of the chosen midpoint.

Impaired neuronal integrity in traumatic brain injury detected by 123I-iomazenil single photon emission computed tomography and MRI.

This study was aiming at investigating the extent of neuronal damage in cases of traumatic brain injury (TBI) with diffuse axonal injury (DAI) using 123I-iomazenil(IMZ) SPECT and MRI. We compared the findings in 31 patients with TBI without any major focal brain lesions and 25 age-matched normal controls. Subjects underwent 123I-IMZ SPECT and MRI, and also assessment by cognitive function tests. The partial volume effect of 123I-IMZ SPECT was corrected using MRI. In the patients with TBI, decreased spatial concentration of 123I-IMZ binding was detected in the medial frontal/orbitofrontal cortex, posterior cingulate gyrus, cuneus, precuneus, and superior region of the cerebellum. ROC analysis of 123I-IMZ SPECT for the detection of neuronal injury showed a high diagnostic ability of 123I-IMZ binding density for TBI in these areas. The decreased 123I-IMZ uptake density in the cuneus and precuneus was associated with cognitive decline after the injury. In the patients with TBI, brain atrophy was detected in the frontal lobe, anterior temporal and parietal cortex, corpus callosum, and posterior part of the cerebellum. Evaluation of the neuronal integrity by 123I-IMZ SPECT and MRI provides important information for the diagnosis and pathological interpretation in cases of TBI with DAI.

Intravenous infusion of auto serum-expanded autologous mesenchymal stem cells in spinal cord injury patients: 13 case series.

BACKGROUND: Although spinal cord injury (SCI) is a major cause of disability, current therapeutic options remain limited. Recent progress in cellular therapy with mesenchymal stem cells (MSCs) has provided improved function in animal models of SCI. We investigated the safety and feasibility of intravenous infusion of MSCs for SCI patients and assessed functional status after MSC infusion. METHODS: In this phase 2 study of intravenous infusion of autologous MSCs cultured in auto-serum, a single infusion of MSCs under Good Manufacturing Practice (GMP) production was delivered in 13 SCI patients. In addition to assessing feasibility and safety, neurological function was assessed using the American Spinal Injury Association Impairment Scale (ASIA), International Standards for Neurological and Functional Classification of Spinal Cord (ISCSCI-92). Ability of daily living was assessed using Spinal Cord Independence Measure (SCIM-III). The study protocol was based on advice provided by the Pharmaceuticals and Medical Devices Agency in Japan. The trial was registered with the Japan Medical Association (JMA-IIA00154). RESULTS: No serious adverse events were associated with MSC injection. There was neurologic improvement based on ASIA grade in 12 of the 13 patients at six months post-MSC infusion. Five of six patients classified as ASIA A prior to MSC infusion improved to ASIA B (3/6) or ASIA C (2/6), two ASIA B patients improved to ASIA C (1/2) or ASIA D (1/2), five ASIA C patients improved and reached a functional status of ASIA D (5/5). Notably, improvement from ASIA C to ASIA D was observed one day following MSC infusion for all five patients. Assessment of both ISCSCI-92, SCIM-III also demonstrated functional improvements at six months after MSC infusion, compared to the scores prior to MSC infusion in all patients. CONCLUSION: While we emphasize that this study was unblinded, and does not exclude placebo effects or a contribution of endogenous recovery or observer bias, our observations provide evidence supporting the feasibility, safety and functional improvements of infused MSCs into patients with SCI.

[A Skilled Typist with Typing Disorder Following Resection of a Left Frontal Lobe Tumor].

We reported a male who showed typing disorders after resection of a tumor in the left posterior superior and middle frontal gyri. He was a right-handed Japanese in his 50s and was good at touch typing as a system engineer. After the tumor resection, he presented typing errors and slightly impaired dexterity of his right fingers. The results of neuropsychological examinations indicated that his typing impairment was not due to aphasia or agraphia of kana letters (Japanese syllabogram). Typing errors were classified into adjacent key, non-adjacent key, omission, and insertion errors. Adjacent key, omission, and insertion errors were commonly found in both words and non-words. Adjacent key errors appeared more frequently in the right hand than the left-hand assigned keys, which may be explained by impaired dexterity of the right fingers associated with the left frontal lesion. Non-adjacent key errors were found exclusively for words and more frequently with the left hand than with the right hand. We consider that the patient's left frontal lesion may have impaired the motor engrams of word typing or its output process necessary to type individual words as a programmed series of pushing keys. (Received November 2, 2018; Accepted July 16, 2019; Published October 1, 2019).

IGF-I regulates tight-junction protein claudin-1 during differentiation of osteoblast-like MC3T3-E1 cells via a MAP-kinase pathway.

Insulin-like growth factor I (IGF-I) is expressed in many tissues, including bone, and acts on the proliferation and differentiation of osteoblasts as an autocrine/paracrine regulator. Tight-junction proteins have been detected in osteoblasts, and direct cell-to-cell interactions may modulate osteoblast function with respect, for example, to gap junctions. In order to investigate the regulation of expression of tight-junction molecules and of function during bone differentiation, osteoblast-like MC3T3-E1 cells and osteocyte-like MLO-Y4 cells were treated with IGF-I. In both MC3T3-E1 cells and MLO-Y4 cells, the tight-junction molecules occludin, claudin-1, -2, and -6, and the gap-junction molecule connexin 43 (Cx43) were detected by reverse transcription with polymerase chain reaction. In MC3T3-E1 cells but not MLO-Y4 cells, mRNAs of claudin-1, -2, and -6, Cx43, and type I collagen, and proteins of claudin-1 and Cx43 were increased after treatment with IGF-I. Such treatment significantly decreased paracellular permeability in MC3T3-E1 cells. The expression of claudin-1 in MC3T3-E1 cells after IGF-I treatment was mainly upregulated via a mitogen-activated protein (MAP)-kinase pathway and, in part, modulated by a PI3-kinase pathway, whereas Cx43 expression and the mediated gap-junctional intercellular communication protein did not contribute to the upregulation. Furthermore, in MC3T3-E1 cells during wound healing, upregulation of claudin-1 was observed together with an increase of IGF-I and type I collagen. These findings suggest that the induction of tight-junction protein claudin-1 and paracellular permeability during the differentiation of osteoblast-like MC3T3-E1 cells after treatment with IGF-I is regulated via a MAP-kinase pathway, but not with respect to gap junctions.

Structural connectivity in spatial attention network: reconstruction from left hemispatial neglect.

Left hemispatial neglect (neglect) is an impaired state of spatial attention. We aimed to reconstruct structural connectivity in the spatial attention network and to identify disconnection patterns underlying neglect. We enrolled 59 right-handed patients who had their first-ever infarction in the right hemisphere and classified them into neglect group (34 patients with neglect) and control group (25 patients without neglect). The neglect group was further subcategorized into 6 subgroups based on infarcted vascular territories. Diffusion tensor imaging data were obtained from all patients. Fractional anisotropy maps were compared between neglect group/subgroups and the control group by using non-parametric voxel-based analysis, generating a lesion path mask. Probabilistic tractography analysis using the lesion path mask reconstructed the following structural connectivity in the spatial attention network, which is specifically damaged in neglect patients: (1) superior longitudinal fasciculus (SLF) I connecting the superior parietal lobule/intraparietal sulcus with the superior frontal gyrus/frontal eye field (SFG/FEF) (dorsal attention network); (2) SLF III/the arcuate fasciculus (AF) and the extreme capsule/inferior fronto-occipital fasciculus (IFOF) connecting the right inferior parietal lobule/temporoparietal junction/superior temporal gyrus (IPL/TPJ/STG) with the middle frontal gyrus/inferior frontal gyrus (ventral attention network); (3) the thalamic radiations to the spatial attention-related cortices; and (4) SLF II and IFOF interconnecting dorsal and ventral attention networks. Individual analysis indicated that isolated damage in SLF I, SLF II, SLF III/AF or the thalamic radiations to IPL/TPJ/STG due to posterior cerebral artery infarction, or simultaneous damage in four thalamic radiations due to anterior choroidal artery infarction, underlies different phenotypes of neglect.

Distribution and Network of Basal Temporal Language Areas: A Study of the Combination of Electric Cortical Stimulation and Diffusion Tensor Imaging.

OBJECTIVE: The basal temporal language area (BTLA) is considered to have several functions in language processing; however, its brain network is still unknown. This study investigated the distribution and networks of the BTLA using a combination of electric cortical stimulation and diffusion tensor imaging (DTI). METHOD: 10 patients with intractable focal epilepsy who underwent presurgical evaluation with subdural electrodes were enrolled in this study (language dominant side: 6 patients, language nondominant side: 4 patients). Electric stimulation at 50 Hz was applied to the electrodes during Japanese sentence reading, morphograms (kanji) reading, and syllabograms (kana) reading tasks to identify the BTLA. DTI was used to identify the subcortical fibers originating from the BTLA found by electric stimulation. RESULTS: The BTLA was found in 6 patients who underwent implantation of the subdural electrodes in the dominant hemisphere. The BTLA was located anywhere between 20 mm and 56 mm posterior to the temporal tips. In 3 patients, electric stimulation of some or all areas within the BTLA induced disturbance in reading of kanji words only. DTI detected the inferior longitudinal fasciculus (ILF) in all patients and the uncinate fasciculus (UF) in 1 patient, originating from the BTLA. ILF was detected from both kanji-specific areas and kanji-nonspecific areas. CONCLUSION: This study indicates that the network of the BTLA is a part of a ventral stream and is mainly composed of the ILF, which acts as a critical structure for lexical retrieval. ILF is also associated with the specific processing of kanji words.

Depressive disorder may be associated with raphe nuclei lesions in patients with brainstem infarction.

BACKGROUND: Depression is a common symptom after stroke, but its neural substrates remain unclear. The ascending serotonergic system originates from the raphe nuclei in the brainstem. We hypothesized that depressive disorder due to brainstem infarction is associated with damage to the raphe nuclei. METHODS: We prospectively enrolled 19 patients who had the first-ever acute isolated brainstem infarction in an observational cross-sectional study. All patients were evaluated by using the Montgomery Åsberg Depression Rating Scale (MADRS), the clinician-rated version of Apathy Evaluation Scale (AES-C) and Mini-Mental State Examination (MMSE). Depressive disorder was diagnosed according to DSM-5 and MADRS score of 12 or greater. Diffusion tensor imaging and proton density-weighted images were used to identify damage in the raphe nuclei. Accordingly, patients were classified into either the raphe-nuclei-damaged or intact group. Prevalence of depressive disorder and the MADRS, AES-C, and MMSE scores were compared between the two groups. RESULTS: Depressive disorder was more frequent in the damaged group (n=6) than in the intact group (n=13) (83% vs. 15%; P=0.01). MADRS scores were higher in the damaged group than in the intact group (mean±1 SD, 17.5±7.9 vs. 7.0±4.4; P=0.002), whereas the AES-C and MMSE scores did not differ between groups. LIMITATIONS: We did not assess the damage to the ascending projection fibers from the raphe nuclei. CONCLUSIONS: Our results suggest that damage to the raphe nuclei underlies depressive disorder due to brainstem infarction, possibly via serotonergic denervation.

What do eye-fixation patterns tell us about unilateral spatial neglect?

PURPOSE: Eye-fixation patterns, which include ocular searching and fixation, may change with tasks, stimuli, and instructions. This article reviews our studies over 18 years on eye-fixation patterns of neglect patients and aims to elucidate the visuospatial processing of unilateral spatial neglect. METHODS: We recorded eye-fixation patterns when patients with neglect bisected a line in various conditions. RESULTS: Patients with neglect rarely searched to the left side when bisecting a line of the ordinary length (e.g., 200 mm). They persisted in fixating a right-side point, at which they later marked the subjective midpoint. They made no effective comparison between the leftward and rightward extents not only for a whole line but also for its explored right segment. Where they 'favored' to fixate as the subjective midpoint depended strongly upon the location of the right endpoint in space. Their representational image of a line was also estimated with modified line bisection tasks performed on a touch-panel display. CONCLUSIONS: For patients with neglect, the representational image of a line may be formed on the basis of the attended segment between the right endpoint and the favored point of fixation. The line bisection task, if combined with recording of eye-fixation, would further contribute to elucidation of the mechanisms underlying neglect.

Approaches to subjective midpoint of horizontal lines in unilateral spatial neglect.

Patients with unilateral spatial neglect usually bisect longer lines with greater rightward errors, while they sometimes err leftward for very short lines (e.g., 25 mm). We analysed movements of eye fixation from the time before line presentation to elucidate whether patients with neglect approach the subjective midpoint differently for lines of various lengths. Four patients with left neglect bisected 200 mm, 100 mm, and 25 mm lines that appeared across the centre of a liquid crystal display (LCD) monitor. The fixation immediately before line presentation was located on average near the centre of the lines. Three of the patients approached the subjective midpoint point directly from the left side in more than 70% of the 200 mm and 100 mm trials. The subjective midpoint frequently deviated leftward on the "attended" segment between the leftmost point of fixation and the right endpoint, while it was displaced rightward on the total extent. The three patients initially explored the 25 mm lines searching for the left endpoint. They thereafter bisected the same lines with leftward errors approaching the subjective midpoint from the left side. The remaining patient searched beyond the right endpoint and in turn approached the subjective midpoint from the right side in about half of the trials and independently of line length. In the 200 mm and 100 mm trials, the subjective midpoint divided the attended right segment nearer to the right endpoint. On the attended right extent of a line, patients with neglect may place the subjective midpoint toward the side from which they approached that point. In the bisection of very short lines, approaches from the left endpoint may cause leftward errors of the subjective midpoint. For longer lines, however, approaches from the left side may result in rightward error of bisection for the total length, as the leftward extent from the fixation immediately before line presentation is hardly explored.