Bilateral and asymmetrical localization of language function identified by the superselective infusion of propofol in an epilepsy patient with a mild malformation of cortical development: illustrative case

BACKGROUND

Atypical localization of language function can result in unexpected postsurgical deficits after cortical resection, but it is difficult to predict the risk in the presurgical evaluation. The authors experienced a rare case of the bilateral and independent existence of different components of language function identified by segmented evaluation of anatomical anterior and posterior language areas using the superselective infusion of propofol.

OBSERVATIONS

A 32-year-old right-handed female presented with drug-resistant epilepsy. Comprehensive epilepsy evaluation suggested that the epileptic foci involved the whole left frontal lobe but provided less evidence of structural abnormality. To estimate the extent of functional deterioration likely to be caused by an extended left frontal lobectomy, the authors evaluated segmented cortical function in the ipsi- and contralateral hemispheres by the superselective infusion of propofol into the branches of the intracranial artery. The results revealed bilateral and asymmetrical localization of language function because the patient presented with different components of aphasia in each hemisphere. Based on the authors' assessment of her functional tolerance, an extended left frontal lobectomy was performed and resulted in neurological deficits within the anticipated range.

LESSONS

An accurate understanding of the correlations between vascular and functional anatomy and the highly specific evaluation of language function provides more advanced presurgical assessment, allowing more tailored planning of cortical resection.

A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

A super-massive Neptune-sized planet

Neptune-sized planets exhibit a wide range of compositions and densities, depending on factors related to their formation and evolution history, such as the distance from their host stars and atmospheric escape processes. They can vary from relatively low-density planets with thick hydrogen-helium atmospheres1,2 to higher-density planets with a substantial amount of water or a rocky interior with a thinner atmosphere, such as HD 95338 b (ref. 3), TOI-849 b (ref. 4) and TOI-2196 b (ref. 5). The discovery of exoplanets in the hot-Neptune desert6, a region close to the host stars with a deficit of Neptune-sized planets, provides insights into the formation and evolution of planetary systems, including the existence of this region itself. Here we show observations of the transiting planet TOI-1853 b, which has a radius of 3.46 ± 0.08 Earth radii and orbits a dwarf star every 1.24 days. This planet has a mass of 73.2 ± 2.7 Earth masses, almost twice that of any other Neptune-sized planet known so far, and a density of 9.7 ± 0.8 grams per cubic centimetre. These values place TOI-1853 b in the middle of the Neptunian desert and imply that heavy elements dominate its mass. The properties of TOI-1853 b present a puzzle for conventional theories of planetary formation and evolution, and could be the result of several proto-planet collisions or the final state of an initially high-eccentricity planet that migrated closer to its parent star.

A temperate Earth-sized planet with tidal heating transiting an M6 star

Temperate Earth-sized exoplanets around late-M dwarfs offer a rare opportunity to explore under which conditions planets can develop hospitable climate conditions. The small stellar radius amplifies the atmospheric transit signature, making even compact secondary atmospheres dominated by N2 or CO2 amenable to characterization with existing instrumentation1. Yet, despite large planet search efforts2, detection of low-temperature Earth-sized planets around late-M dwarfs has remained rare and the TRAPPIST-1 system, a resonance chain of rocky planets with seemingly identical compositions, has not yet shown any evidence of volatiles in the system3. Here we report the discovery of a temperate Earth-sized planet orbiting the cool M6 dwarf LP 791-18. The newly discovered planet, LP 791-18d, has a radius of 1.03 ± 0.04 R⊕ and an equilibrium temperature of 300-400 K, with the permanent night side plausibly allowing for water condensation. LP 791-18d is part of a coplanar system4 and provides a so-far unique opportunity to investigate a temperate exo-Earth in a system with a sub-Neptune that retained its gas or volatile envelope. On the basis of observations of transit timing variations, we find a mass of 7.1 ± 0.7 M⊕ for the sub-Neptune LP 791-18c and a mass of [Formula: see text] for the exo-Earth LP 791-18d. The gravitational interaction with the sub-Neptune prevents the complete circularization of LP 791-18d's orbit, resulting in continued tidal heating of LP 791-18d's interior and probably strong volcanic activity at the surface5,6.

Double-lumen Carotid Plaque Associated with Severe Stenosis Treated with Staged Angioplasty: A Case Report

Double-lumen carotid plaque is a rare pathological condition, and only few reports about this condition have been recorded in the literature. However, no study has used endovascular therapy (EVT) for the treatment of double-lumen carotid plaque. Herein, we present a unique case of double-lumen carotid plaque associated with severe stenosis that was successfully treated with staged angioplasty (SAP). Moreover, a literature review of its pathology and other treatment options has been conducted. SAP is a two-stage carotid artery stenting (CAS) that can prevent hyperperfusion syndrome after revascularization. In this study, a 62-year-old man developed walking disturbance and left hemiparesis. Magnetic resonance imaging (MRI) revealed ischemic lesions in the watershed area of the right hemisphere and an irregular plaque in the right cervical internal carotid artery (ICA). Ultrasonography showed 84% stenosis in the area and a double lumen distal to the stenosis in the right ICA. Digital subtraction angiography (DSA) revealed a double-lumen plaque with 70% stenosis based on the North American Symptomatic Carotid Endarterectomy Trial criteria. SAP was performed after medication therapy and rehabilitation, and the surgery was uneventful. A double-lumen carotid plaque associated with severe stenosis is a rare condition with a high risk of emboli and stroke. In an unstable lesion, carotid endarterectomy is the first option. However, since the patient in this case was at high risk for general anesthesia, SAP was performed. Hence, if an appropriate device is used, EVT can be a safe treatment strategy for unstable and atypical plaques as in this case.

Endoscopically Treated Subacute Subdural Hematoma Presenting Postoperative Cerebral Hyperperfusion Syndrome: Chronological Changes of Cerebral Blood Flow on Arterial Spin Labeling and Subcortical Low Intensity on Fluid-attenuated Inversion Recovery Images

Subacute subdural hematoma (SASDH) is a neurotraumatic entity. There are few reports of chronological changes of cerebral blood flow (CBF) on arterial spin labeling (ASL) and subcortical low intensity (SCLI) on fluid-attenuated inversion recovery (FLAIR) images of magnetic resonance imaging (MRI) observations from the injury onset, deterioration, to post-surgery. We reported a SASDH patient presenting postoperative cerebral hyperperfusion (CHP) syndrome with chronological changes of those findings. An 85-year-old woman fell and presented right ASDH. She was treated conservatively due to no neurological deficits. On day 3, ASL image revealed increased CBF against brain compression. On day 7, the CBF was normalized on ASL image, but SCLI was confirmed. On day 14, SCLI was strengthened. Then she developed left hemiparesis due to brain compression by SASDH. Considering age and comorbidities, we performed endoscopic hematoma removal under local anesthesia, and her neurological deficits improved after the surgery. On postoperative day 1, she newly presented left upper limb paresis. MRI revealed increased CBF and enhanced SCLI. We diagnosed CHP syndrome, and antihypertensive treatment improved the symptoms gradually. However, SCLI had been consistently observed, and CBF easily changed depending on the blood pressure, suggesting dysfunction of the CBF autoregulation. We showed the endoscopically treated SASDH patient with CBF’s chronological changes on ASL images and SCLI on FLAIR images. Long-time brain compression would lead to dysfunction of the CBF autoregulation, and we should be careful about CHP syndrome after the endoscopic surgery for SASDH.

GJ 367b: A dense, ultrashort-period sub-Earth planet transiting a nearby red dwarf star

[Figure: see text].

Deep Learning-Based Functional Independence Measure Score Prediction After Stroke in Kaifukuki (Convalescent) Rehabilitation Ward Annexed to Acute Care Hospital

Introduction

Prediction models of functional independent measure (FIM) score after kaifukuki (convalescent) rehabilitation ward (KRW) are needed to decide the treatment strategies and save medical resources. Statistical models were reported, but their accuracies were not satisfactory. We made such prediction models using the deep learning (DL) framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan).

Methods

Of the 559 consecutive stroke patients, 122 patients were transferred to our KRW. We divided our 122 patients’ data randomly into halves of training and validation datasets. Prediction One made three prediction models from the training dataset using (1) variables at the acute care ward admission, (2) those at the KRW admission, and (3) those combined (1) and (2). The models’ determination coefficients (R²), correlation coefficients (rs), and residuals were calculated using the validation dataset.

Results

Of the 122 patients, the median age was 71, length of stay (LOS) in acute care ward 23 (17-30) days, LOS in KRW 53 days, total FIM scores at the admission of KRW 85, those at discharge 108. The mean FIM gain and FIM efficiency were 19 and 0.417. All patients were discharged home. Model (1), (2), and (3)’s R² were 0.794, 0.970, and 0.972. Their mean residuals between the predicted and actual total FIM scores were -1.56±24.6, -4.49±17.1, and -2.69±15.7.

Conclusion

Our FIM gain and efficiency were better than national averages of FIM gain 17.1 and FIM efficiency 0.187. We made DL-based total FIM score prediction models, and their accuracies were superior to those of previous statistically calculated ones. The DL-based FIM score prediction models would save medical costs and perform efficient stroke and rehabilitation medicine.

A Case of Traumatic Cerebrospinal Fluid Rhinorrhea Successfully Treated Using Intravenous Factor XIII Administration

Traumatic cerebrospinal fluid (CSF) rhinorrhea occurs around 2% of severe head trauma. We should find the fistula and surgically seal it or perform conservative therapy with bed rest with/without lumbar spinal CSF drainage. However, the fistula may not be identified, and treatment may sometimes be challenging. Blood coagulation factor XIII (factor XIII) is one of the blood coagulation factors. It also promotes fibroblast proliferation during the wound healing process. We herein reported a traumatic CSF rhinorrhea patient who was successfully treated using intravenous (IV) factor XIII administration. This report would contribute to the effectiveness of factor XIII administration in the treatment of traumatic CSF rhinorrhea. A 58-year-old man fell from a height of 1.5 meters and hit his forehead. He presented with numbness in both upper limbs but no paresis. Neck magnetic resonance imaging (MRI) revealed cervical spinal cord injury without a cervical vertebral or cranial fracture. He was conservatively treated and discharged after three months. He had been aware of rhinorrhea since the trauma but was treated as allergic rhinitis. A year after the trauma, he was diagnosed with traumatic CSF rhinorrhea. We confirmed a bit of rhinorrhea despite the seven-day bedrest, so we intravenously administered 240 international units of factor XIII every day for 10 days. After 10 days, there was no rhinorrhea at all, and the patient was discharged on the 28th day. He has had no recurrence of rhinorrhea after a three-month follow-up. Factor XIII administration might be useful to treat traumatic CSF rhinorrhea.

Chronic subdural hematoma in patients over 65 years old: Results of using a postoperative cognitive evaluation to determine whether to permit return to driving

Background:

Chronic subdural hematoma (CSDH) is usually associated with good recovery with burr hole irrigation and postoperative drainage under local anesthesia. In Japan, traffic accidents by the elderly drivers over 65 years old are severely increasing, and there is no consensus on whether or not to return to driving after CSDH treatment. We perform a postoperative cognitive assessment. We retrospectively investigated the return-to-driving rate and associated factors.

Methods:

Of the 45 patients over 65 y.o. and who had usually driven, 30 patients wished to drive again. We performed tests composed of Mini-Mental State Examination (MMSE), line cancellation and line bisection task, Kohs block design test, trail making test (TMT)-A and B, Kana-hiroi test, Rey-Osterrieth complex figure test, and behavioral assessment of the dysexecutive syndrome, in order. When all tests’ scores were better than the cutoff values, we let patients drive again. When some of the scores were worse than the cutoff values, we reevaluated the patients at the outpatient every month. If the patients’ scores could not improve at the outpatient, we recommended them to stop driving.

Results:

Nineteen of 30 patients could return to driving. Worse MMSE, Kohs block design test, TMT-A, TMT-B scores, higher age, dementia, or consciousness disturbance as chief complaints were associated with driving disability.

Conclusion:

CSDH is known as treatable dementia. However, we should perform an objective cognitive assessment before discharge because only 63% of the patients over 65 y.o. who wished to drive could return to driving.

A case with bilateral thalamic infarction manifesting mutism - Cerebral blood flow and neural fibers evaluation

Background:

Acute bilateral thalamic infarction is rare, and occlusion of the artery of percheron (AOP) may be one of its reasons. AOP occlusion results in an acute disturbance of consciousness, but mutism due to AOP occlusion is rare. We described a mutism patient with bilateral thalamic infarction presumably due to AOP occlusion. We also performed cerebral blood flow (CBF) evaluation by N-isopropyl-p-[¹²³I]-iodoamphetamine single-photon emission computed tomography (¹²³I-IMP-SPECT) as well as neural fiber evaluation by diffusion tensor tractography, discussing the mechanism of mutism.

Case Description:

A 92-year-old woman presented a gradual deterioration of consciousness. Diffusion-weighted images revealed high-intensity areas at the bilateral thalami, and we diagnosed AOP occlusion. We administered a recombinant tissue plasminogen activator. On day 14, her Glasgow Coma Scale score was 11 (E4V1M6), and she did not present any apparent paresis. She was mute but cognitively alert, although she could communicate by nodding or facial expression. ¹²³I-IMP-SPECT showed CBF increase in the bilateral cerebellum and CBF decrease in the infarcted bilateral thalami and frontal lobes. Diffusion tensor tractography revealed the bilateral dentatothalamo-cortical tracts (DTCs). However, the tracts terminated at the parieto-occipital cortex, but not at the frontal cortex. She still had mutism on day 30.

Conclusion:

We reported the bilateral thalamic infarction patient presumably due to AOP occlusion, who presented mutism. The discontinuity of the bilateral DTCs resulted in her mutism, and our results supported the hypothesis that the cerebellum plays a significant role in uttering, associated with the bilateral DTCs.

A nearby transiting rocky exoplanet that is suitable for atmospheric investigation

Spectroscopy of transiting exoplanets can be used to investigate their atmospheric properties and habitability. Combining radial velocity (RV) and transit data provides additional information on exoplanet physical properties. We detect a transiting rocky planet with an orbital period of 1.467 days around the nearby red dwarf star Gliese 486. The planet Gliese 486 b is 2.81 Earth masses and 1.31 Earth radii, with uncertainties of 5%, as determined from RV data and photometric light curves. The host star is at a distance of ~8.1 parsecs, has a J-band magnitude of ~7.2, and is observable from both hemispheres of Earth. On the basis of these properties and the planet's short orbital period and high equilibrium temperature, we show that this terrestrial planet is suitable for emission and transit spectroscopy.

Lance-Adams Syndrome Treated by Perampanel in the Acute Term

Lance-Adams syndrome (LAS) is chronic post-hypoxic myoclonus after a hypoxic encephalopathy. Recently, the report on LAS in the chronic term treated by perampanel (PER) is increasing. However, PER’s efficacy in the “acute term” has not been reported. Here, we report an LAS patient who markedly improved when PER was added to his existing treatment regime in the acute term. The 65-year-old patient presented with a return of spontaneous circulation after cardiopulmonary arrest. He developed myoclonus on the admission day, and it led to tonic-clonic convulsion. We started levetiracetam 3000 mg/day, lacosamide 400 mg/day, general anesthesia using midazolam 180 mg/day, dexmedetomidine 1000 μg/day, and fentanyl 1.2 mg/day. We could stop the convulsions after 18 h from the onset. We tried to reduce sedatives, but his convulsion recurred. We added PER 2 mg/day for three days, PER 4 mg/day for next four days, then used PER 8 mg/day and we could gradually reduce the sedatives. Single-photon emission computed tomography on day 40 showed cerebral blood flow (CBF) increase at the bilateral anterior lobes of the cerebellum, medial temporal lobes, and supplementary motor and premotor areas, while CBF decrease at the brain surface of the frontal, parietal, and temporal lobes. The myoclonus disappeared since day 12, and he was transferred to another rehabilitation hospital on day 56. The optimal treatment strategy has not been established for LAS, but our case suggested that PER could be one of the choices to treat LAS in the acute term.

Standard values for temporal muscle thickness in the Japanese population who undergo brain check-up by magnetic resonance imaging

BACKGROUND

Skeletal muscle mass is an important factor for various diseases' outcomes. The psoas muscle cross-sectional area on the abdominal computed tomography (CT), gait speed, and handgrip strength is used to measure it. However, it is difficult to measure the neurological patients' muscle mass or function because (1) we do not perform abdominal CT. (2) Such patients have impaired consciousness, gait disturbance, paresis, and need of rest. Temporal muscle thickness (TMT) on magnetic resonance imaging (MRI) is now attractive for skeletal muscle volume indicator, but the reference values are not established. We herein investigated the standard value of the Japanese TMT using the brain check-up database by MRI.

METHODS

We retrospectively investigated 360 Japanese individuals from two institutions between 2017 and 2019. We measured TMT on the T1-weighted images in the previously reported way. The associations between TMT and other variables were analyzed.

RESULTS

TMT of 214 women and 146 men, ranging from 35 to 84 years old, was investigated. TMT ranged from 3.69 to 16.90 mm. Mean TMT values were significantly higher in men compared to women except for the over 70-year-old cohort. TMT was correlated to weight and body mass index in both sexes.

CONCLUSION

This is the first retrospective study on the standard TMT values from the Japanese brain check-up database. Our results were just reference values, but these would be useful for further investigation in other neurosurgical and neurological diseases regarding muscle volume or sarcopenia.

Where to make burr hole for endoscopic hematoma removal against intracerebral hemorrhage at the basal ganglia to increase the hematoma removal rate - Comparison between trans-forehead and along-the-long-axis approaches

Background:

Endoscopic hematoma removal is performed to treat intracerebral hemorrhage (ICH) at the basal ganglia. In our hospital, young neurosurgical trainees perform it for the only 1^st to the 3^rd time. We perform a “trans-forehead approach” and hypothesized that our technique would contribute to higher hematoma removal rate and easiness despite their inexperience. We compared our dataset with an open dataset with along-the-long-axis approaches using pre- and intraoperative neuronavigation by well-trained neurosurgeons and tested the utility of our trans-forehead approach.

Methods:

We retrospectively investigated our 17 consecutive patients with hypertensive ICH who underwent endoscopic hematoma removal using the trans-forehead approach. We obtained the open dataset and compared our data with the 12 patients from the open dataset using the inverse probability weighting method. Operative time, hematoma removal rate, postoperative hematoma volume, Glasgow Coma Scale (GCS) on day 7, and modified Rankin Scale (mRS) at 6 months were assessed as outcomes.

Results:

The median age was 68 (interquartile range; 58–78) years. Median postoperative hematoma volume, removal rate, operative time, GCS on day 7, and mRS at 6 months were 9 (2–24) mL, 90 (79–98)%, 53 (41–80) min, 13 (12–13), and 4 (2–5), respectively. The weighted generalized estimating equations revealed that operative time was shorter in the along-the-long-axis group, but other items were not significantly different between the two approaches.

Conclusion:

The hematoma removal rate of endoscopic hematoma removal with the trans-forehead approach by young trainees was not different from that of the along-the-long-axis approach by well-trained neurosurgeons using neuronavigation.

Prediction Model of Deep Learning for Ambulance Transports in Kesennuma City by Meteorological Data

PURPOSE

With the aging population in Japan, the prediction of ambulance transports is needed to save the limited medical resources. Some meteorological factors were risks of ambulance transports, but it is difficult to predict in a classically statistical way because Japan has 4 seasons. We tried to make prediction models for ambulance transports using the deep learning (DL) framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), with the meteorological and calendarial variables.

MATERIALS AND METHODS

We retrospectively investigated the daily ambulance transports and meteorological data between 2017 and 2019. First, to confirm their association, we performed classically statistical analysis. Second, to test the DL framework's utility for ambulance transports prediction, we made 3 prediction models for daily ambulance transports (total daily ambulance transports more than 5 or not, cardiopulmonary arrest (CPA), and trauma) using meteorological and calendarial factors and evaluated their accuracies by internal cross-validation.

RESULTS

During the 1095 days of 3 years, the total ambulance transports were 5948, including 240 CPAs and 337 traumas. Cardiogenic CPA accounted for 72.3%, according to the Utstein classification. The relation between ambulance transports and meteorological parameters by polynomial curves were statistically obtained, but their r2s were small. On the other hand, all DL-based prediction models obtained satisfactory accuracies in the internal cross-validation. The areas under the curves obtained from each model were all over 0.947.

CONCLUSION

We could statistically make polynomial curves between the meteorological variables and the number of ambulance transport. We also preliminarily made DL-based prediction models. The DL-based prediction for daily ambulance transports would be used in the future, leading to solving the lack of medical resources in Japan.

Preliminary development of a prediction model for daily stroke occurrences based on meteorological and calendar information using deep learning framework (Prediction One; Sony Network Communications Inc., Japan)

BACKGROUND

Chronologically meteorological and calendar factors were risks of stroke occurrence. However, the prediction of stroke occurrences is difficult depending on only meteorological and calendar factors. We tried to make prediction models for stroke occurrences using deep learning (DL) software, Prediction One (Sony Network Communications Inc., Tokyo, Japan), with those variables.

METHODS

We retrospectively investigated the daily stroke occurrences between 2017 and 2019. We used Prediction One software to make the prediction models for daily stroke occurrences (present or absent) using 221 chronologically meteorological and calendar factors. We made a prediction models from the 3-year dataset and evaluated their accuracies using the internal cross-validation. Areas under the curves (AUCs) of receiver operating characteristic curves were used as accuracies.

RESULTS

The 371 cerebral infarction (CI), 184 intracerebral hemorrhage (ICH), and 53 subarachnoid hemorrhage patients were included in the study. The AUCs of the several DL-based prediction models for all stroke occurrences were 0.532-0.757. Those for CI were 0.600-0.782. Those for ICH were 0.714-0.988.

CONCLUSION

Our preliminary results suggested a probability of the DL-based prediction models for stroke occurrence only by meteorological and calendar factors. In the future, by synchronizing a variety of medical information among the electronic medical records and personal smartphones as well as integrating the physical activities or meteorological conditions in real time, the prediction of stroke occurrence could be performed with high accuracy, to save medical resources, to have patients care for themselves, and to perform efficient medicine.

Unilateral posterior reversible encephalopathy syndrome characterized with a long and gradually exacerbating course over 3 years and that presented propofol infusion syndrome - A case report

Background:

Posterior reversible encephalopathy syndrome (PRES) is characterized by acute neurological symptoms and vasogenic edema, and most patients wholly recover. We report a unilateral PRES patient characterized by a gradual onset followed by propofol infusion syndrome (PRIS) due to general anesthesia therapy.

Case Description:

A 32-year-old woman had ovarian dysfunction treated by Kaufmann’s treatment for 17 years. Three years ago, she developed seizures, and photophobia and myoclonus sometimes occurred. This time, she had strong photophobia and nausea for 3 months and then developed tonic-clonic seizures for 3 min. Her blood pressure and laboratory test on admission were all within normal limits. She presented no neurological deficits at admission, but the T2-weighted image (T2WI) showed a high-intensity area (HIA), and arterial spin labeling (ASL) image described cerebral blood flow (CBF) increase in the left parieto-occipital region. We diagnosed PRES and started anticonvulsants, antihypertensive, and steroid pulse therapy. However, her aphasia and neuroimaging findings worsened, so we started general anesthesia treatment with propofol on day 29. On day 32, she suddenly developed multiple organ dysfunctions due to PRIS. After intensive care with other sedatives over 2 months, the systemic status and neurological symptoms gradually improved almost as before the onset. On day 90, HIA in the T2WI in the lesion became small, and CBF was severely downregulated in the ASL image.

Conclusion:

Unilateral PRES’s pathophysiology and the association with the female hormone remain unknown. Some patients undergo gradual onset and long-term courses, and we should care for PRIS during PRES treatment.

Musician developed right putaminal hemorrhage but conserved absolute pitch ability -Case report

Absolute pitch (AP) is known as the ability to recognize and label the pitch chroma of a given tone without external reference. The neural mechanism and its asymmetry of AP musicians remain unclear. We herein report a 41-year-old AP musician who developed a right putaminal hemorrhage. On a postoperative day 5, a fluid-attenuated inversion recovery image revealed the rest of the hematoma and edematous lesion at the right white matter between the Heschl's gyrus and other cortices. Diffusion tensor tractography with the region of interest at the Heschl's gyrus was performed. In the left hemisphere, the anterior part of the arcuate fiber and middle longitudinal fasciculus were observed. However, these connections were absent in the right hemisphere, but her AP ability was maintained. Our case suggested that the fibers from the right Heschl's gyrus to the right frontal lobe via the right ventral stream is not associated with AP.

Usefulness of 3 Tesla Ultrashort Echo Time Magnetic Resonance Angiography (UTE-MRA, SILENT-MRA) for Evaluation of the Mother Vessel after Cerebral Aneurysm Clipping: Case Series of 19 Patients

It is important to assess the cerebral arteries near the clip after cerebral aneurysm clipping. Contrast-enhanced computed tomography angiography has side effects of contrast medium and radiation exposure. Time-of-flight magnetic resonance angiography (TOF-MRA) is a fast and non-invasive method, but clip-induced artifact limits the assessment around the clip. Recently, 3 tesla MRA with ultrashort echo time called SILENT MRA (GE Healthcare Life Sciences, UK) has been reported to have the potential to overcome these disadvantages. We herein present consecutive 19 cerebral aneurysm patients treated by clipping and evaluated using SILENT MRA. The 19 patients (15 women and 4 men) underwent TOF-MRA and SILENT MRA during the same scan session. Two neurosurgeons independently assessed the visibility of the mother vessel at the clipping site in TOF-MRA and SILENT MRA. We also investigated the factors related to visibility in SILENT MRA. All patients’ mother vessels were not described in TOF-MRA, and that of 16 patients (84%) were described in SILENT MRA. Overall agreement was 100% in the two neurosurgeons, and the fixed marginal kappa = 1.00 (95% CI: 0.36–1.00). Univariate analysis revealed that larger aneurysm dome and long clip blade length contributed to the visibility of the mother vessel in SILENT MRA. (p = 0.023, 0.007, each). In conclusion, SILENT MRA can be applied for the assessment of the arteries and aneurysm neck remnants near the clip. Using clips with long blade and ligation with its tip would be related to the visibility of the mother vessels in SILENT MRA.

Preliminary development of a deep learning-based automated primary headache diagnosis model using Japanese natural language processing of medical questionnaire

Background

Primary headaches are widespread and costly public health problems. However, there are insufficient medical resources for their treatment in Japan due to two reasons. First, the numbers of headache specialists and clinics remain insufficient. Second, neurologists and neurosurgeons mainly treat headaches in Japan. However, they mainly work as general stroke neurologists, so they cannot focus on primary headache treatment. To solve these problems, we preliminarily developed a deep learning (DL)-based automated diagnosis model from patients' Japanese unstructured sentences in the medical questionnaire using a DL framework. We hypothesized that the model would reduce the time and burden on both doctors and patients and improve their quality of life.

Methods

We retrospectively investigated our primary headache database and developed a diagnosis model using the DL framework (Prediction One, Sony Network Communications Inc., Japan). We used age, sex, date, and embedding layer made by the medical questionnaire's natural language processing (NLP).

Results

Eight hundred and forty-eight primary headache patients (495 women and 353 men) are included. The median (interquartile range) age was 59 (40-74). Migraine accounted for 46%, tension-type headache for 47%, trigeminal autonomic cephalalgias for 5%, and other primary headache disorders for 2%. The accuracy, mean precision, mean recall, and mean F value of the developed diagnosis model were 0.7759, 0.8537, 0.6086, and 0.6353, which were satisfactory.

Conclusion

The DL-based diagnosis model for primary headaches using the raw medical questionnaire's Japanese NLP would be useful in performing efficient medical practice after ruling out the secondary headaches.

A giant planet candidate transiting a white dwarf

Astronomers have discovered thousands of planets outside the Solar System¹, most of which orbit stars that will eventually evolve into red giants and then into white dwarfs. During the red giant phase, any close-orbiting planets will be engulfed by the star², but more distant planets can survive this phase and remain in orbit around the white dwarf^3,4. Some white dwarfs show evidence for rocky material floating in their atmospheres⁵, in warm debris disks^6-9 or orbiting very closely^10-12, which has been interpreted as the debris of rocky planets that were scattered inwards and tidally disrupted¹³. Recently, the discovery of a gaseous debris disk with a composition similar to that of ice giant planets¹⁴ demonstrated that massive planets might also find their way into tight orbits around white dwarfs, but it is unclear whether these planets can survive the journey. So far, no intact planets have been detected in close orbits around white dwarfs. Here we report the observation of a giant planet candidate transiting the white dwarf WD 1856+534 (TIC 267574918) every 1.4 days. We observed and modelled the periodic dimming of the white dwarf caused by the planet candidate passing in front of the star in its orbit. The planet candidate is roughly the same size as Jupiter and is no more than 14 times as massive (with 95 per cent confidence). Other cases of white dwarfs with close brown dwarf or stellar companions are explained as the consequence of common-envelope evolution, wherein the original orbit is enveloped during the red giant phase and shrinks owing to friction. In this case, however, the long orbital period (compared with other white dwarfs with close brown dwarf or stellar companions) and low mass of the planet candidate make common-envelope evolution less likely. Instead, our findings for the WD 1856+534 system indicate that giant planets can be scattered into tight orbits without being tidally disrupted, motivating the search for smaller transiting planets around white dwarfs.

Three tesla magnetic resonance angiography with ultrashort echo time describes the arteries near the cerebral aneurysm with clip and the peripheral cerebral arteries

Background:

The assessment of the clipped cerebral aneurysm and the cerebral arteries after the treatment of subarachnoid hemorrhage (SAH) is important to find aneurysm regrowth or postoperative cerebral vasospasm. Usually, contrast-enhanced computed tomography angiography is performed for the evaluation of the arteries, but it has side effects of contrast medium. Time-of-flight magnetic resonance angiography (MRA) is a fast and non-invasive method, but clip-induced artifact limits assessment of the artery in the vicinity of the clip. 1.5T MRA with ultrashort echo time (UTE) reduces metal artifact, but the obtained image is too rough to evaluate the aneurysm remnant, and the description range is too narrow to assess the cerebral vasospasm. We routinely use SIGNA Pioneer 3.0T (GE Healthcare Life Sciences, Buckinghamshire, England) and perform SILENT SCAN with UTE-MRA for the postoperative assessment of the clipped aneurysm and cerebral arteries for SAH patients treated by clipping. It has better image quality and describes arteries with a wide description range, so it possesses the potential to overcome the disadvantages of 1.5T UTE-MRA.

Case Description:

We presented a representative SAH patient who postoperatively underwent 3.0T UTE- MRA after clipping. The artery near the clipped aneurysm was evaluated in detail, and the cerebral arteries were described from the main trunk to the peripheral parts with a wide description range, which enabled the assessment of cerebral vasospasm.

Conclusion:

3.0T UTE-MRA may be helpful for the usual assessment of the arteries after clipping and cerebral vasospasm in the future.

P856Incidence and Outcomes of irregular protrusion after stent implantation in patients with acute myocardial infarction: An in in vivo optical coherence tomography study

Background

Irregular protrusion, a protrusion of material with an irregular surface into the lumen of the vessel after stent implantation, can only be identified by optical coherence tomography (OCT). A previous study demonstrated that irregular protrusion after stent implantation was an independent predictor of 1-year major adverse cardiac events (MACE) in CAD patients. However, the true incidence and prognostic significance of irregular protrusion after stenting in patients with ST-segment elevation myocardial infarction (STEMI) have not previously examined.

Aims

The aims of this study were the following: 1) to evaluate the incidence of irregular protrusion detected by OCT in STEMI patients after stenting; and 2) to compare the long-term outcomes between patients with and without irregular protrusion.

Methods and results

A total of 210 STEMI patients who had post-procedure OCT imaging after coronary stenting within 12 hours after symptom onset were studied. We divided them into two groups: those with irregular protrusion (n=159) and those without (n=51) after stenting. There were no significant differences in baseline characteristics between the 2 groups except that peak CK-MB levels were higher in patients with irregular protrusion than those without (289 (137–563) vs. 260 (63–349) U/L, p<0.05). During mean follow-up period of 298 days, the overall incidence of MACE defined as cardiac death, target vessel-related myocardial infarction, and target lesion revascularization was 15.3%. Kaplan-Meier curve showed that the incidence of MACE did not differ between patients with and without irregular protrusion (14.7% vs. 17.7%, p=0.53 by Log-rank).

Conclusions

Irregular protrusion after stent implantation was detected in three-fourth of STEMI patients. Although patients with irregular protrusion had a greater myocardial damage, it did not influence clinical outcomes.

Acknowledgement/Funding

Donation course from Abbott Japan

Exoplanet Biosignatures: Understanding Oxygen as a Biosignature in the Context of Its Environment

We describe how environmental context can help determine whether oxygen (O2) detected in extrasolar planetary observations is more likely to have a biological source. Here we provide an in-depth, interdisciplinary example of O2 biosignature identification and observation, which serves as the prototype for the development of a general framework for biosignature assessment. Photosynthetically generated O2 is a potentially strong biosignature, and at high abundance, it was originally thought to be an unambiguous indicator for life. However, as a biosignature, O2 faces two major challenges: (1) it was only present at high abundance for a relatively short period of Earth's history and (2) we now know of several potential planetary mechanisms that can generate abundant O2 without life being present. Consequently, our ability to interpret both the presence and absence of O2 in an exoplanetary spectrum relies on understanding the environmental context. Here we examine the coevolution of life with the early Earth's environment to identify how the interplay of sources and sinks may have suppressed O2 release into the atmosphere for several billion years, producing a false negative for biologically generated O2. These studies suggest that planetary characteristics that may enhance false negatives should be considered when selecting targets for biosignature searches. We review the most recent knowledge of false positives for O2, planetary processes that may generate abundant atmospheric O2 without a biosphere. We provide examples of how future photometric, spectroscopic, and time-dependent observations of O2 and other aspects of the planetary environment can be used to rule out false positives and thereby increase our confidence that any observed O2 is indeed a biosignature. These insights will guide and inform the development of future exoplanet characterization missions. Key Words: Biosignatures-Oxygenic photosynthesis-Exoplanets-Planetary atmospheres. Astrobiology 18, 630-662.

Red-edge position of habitable exoplanets around M-dwarfs

One of the possible signs of life on distant habitable exoplanets is the red-edge, which is a rise in the reflectivity of planets between visible and near-infrared (NIR) wavelengths. Previous studies suggested the possibility that the red-edge position for habitable exoplanets around M-dwarfs may be shifted to a longer wavelength than that for Earth. We investigated plausible red-edge position in terms of the light environment during the course of the evolution of phototrophs. We show that phototrophs on M-dwarf habitable exoplanets may use visible light when they first evolve in the ocean and when they first colonize the land. The adaptive evolution of oxygenic photosynthesis may eventually also use NIR radiation, by one of two photochemical reaction centers, with the other center continuing to use visible light. These “two-color” reaction centers can absorb more photons, but they will encounter difficulty in adapting to drastically changing light conditions at the boundary between land and water. NIR photosynthesis can be more productive on land, though its evolution would be preceded by the Earth-type vegetation. Thus, the red-edge position caused by photosynthetic organisms on habitable M-dwarf exoplanets could initially be similar to that on Earth and later move to a longer wavelength.

Fourth Ventricle Outlet Obstruction with Expanding Space on the Surface of Cerebellum

BACKGROUND

Hydrocephalus is classified as noncommunicating and communicating based on whether all ventricular and subarachnoid spaces are communicating. Although the diagnosis between the two different states is crucial, it is difficult in certain conditions. In particular, communicating hydrocephalus and noncommunicating hydrocephalus owing to fourth ventricle outlet obstruction are highly misdiagnosed. We describe a case of fourth ventricle outlet obstruction of unknown origin that was initially misdiagnosed as communicating hydrocephalus.

CASE DESCRIPTION

A 66-year-old woman with gait disturbance and incontinence caused by hydrocephalus underwent ventriculoperitoneal shunt surgery. After 9 months, her fourth ventricle became enlarged and could not be controlled by lowering the shunt pressure. Magnetic resonance imaging (MRI) demonstrated obstruction at the foramen of Magendie, foramina of Luschka, and the cerebral aqueduct. Endoscopic surgery for aqueduct plasty with third ventriculostomy was planned. Because the aqueduct was observed to open spontaneously, only the standard third ventriculostomy was performed. When MRI findings were reviewed retrospectively, an unnatural space was observed between the lower cranial nerves and cerebellar hemisphere that grew along with the fourth ventricular enlargement. This space was determined by MRI cisternography to be the cystic membrane ballooning out from the foramen of Luschka. The primary hydrocephalus likely resulted from fourth ventricle outlet obstruction.

CONCLUSIONS

Enlargement of the whole ventricular system with an expanded space between the lower cranial nerves and cerebellar hemisphere can be caused by fourth ventricle outlet obstruction. In such cases, preoperative evaluation of anatomic architecture and cerebrospinal fluid obstruction using MRI cisternography is essential and leads to a successful endoscopic strategy.

Total regression of brain metastases in non-small cell lung cancer patients harboring EGFR mutations treated with gefitinib without radiotherapy: two case reports

Background

Gefitinib is an epidermal growth factor receptor tyrosine kinase inhibitor. Clinical trials have reported its effectiveness in the treatment of brain metastases from non-small cell lung cancer by overcoming the blood–brain barrier. Gefitinib is generally regarded as a relatively safe agent, and several reports have described its efficacy in patients with epidermal growth factor receptor mutation-positive non-small cell lung cancer and a poor performance status.

Case presentation

We herein described two patients with brain metastasis from non-small cell lung cancer who achieved the total regression of metastasis with the administration of gefitinib. A 70-year-old Japanese woman was referred to our hospital with a severe cough. Brain magnetic resonance imaging revealed a metastatic lesion in the left temporal lobe. The tumor was positive for an epidermal growth factor receptor L858R mutation in exon 21 using the peptide nucleic acid-locked nucleic acid polymerase chain reaction clamp method. She was treated with 250 mg gefitinib per day, and, 1 month later, the primary lesion and brain metastasis had totally resolved. A 58-year-old Japanese woman was referred to our hospital with nausea and headache. Brain magnetic resonance imaging revealed a metastatic lesion in the left cerebellar hemisphere and meningeal dissemination. The tumor was positive for the epidermal growth factor receptor L858R mutation in exon 21. She was treated with 250 mg gefitinib per day, and, 3 weeks later, the primary lesion, brain metastasis, and meningeal dissemination had completely resolved.

Conclusion

We successfully treated two lung cancer patients with brain metastasis using gefitinib. Gefitinib therapy may be a suitable treatment for brain metastasis in lung cancer with an epidermal growth factor receptor mutation, particularly in elderly patients with a poor performance status.

Snapping pes syndrome after total knee arthroplasty

Snapping syndrome rarely occurs at the knee joint. This is the first report of snapping pes syndrome after total knee arthroplasty. Surgeons should be aware of the presence of such a case and pay attention to the fact that snapping symptoms could be caused by a residual bony prominence and a change in alignment after total knee arthroplasty.

Compression neuropathy caused by cancer metastasis to the optic nerve canal

Background

Cancerous cells are known to metastasize to different ocular structures. This happens especially to the choroid in males with lung cancer and females with breast cancer. However, we observed two cases of cancerous metastasis to the optic canal region. Both cases showed only a progressive decrease in vision without any other remarkable ophthalmological symptoms or abnormalities in the affected eye.

Case presentation

Two females, a 60-year-old and a 73-year-old, came to our hospital because of progressive loss of vision. These patients showed no remarkable symptoms or signs in their eyes except visual acuity loss. Several ophthalmoscopic examinations, such as slit lamp microscopy and fundoscopy, showed no abnormal changes in their affected eye but magnetic resonance imaging indicated a massive legion around the optic nerve.

Conclusion

It is possible for cancer to metastasize to the optic canal region and the existence of primary tumors should be considered.

Increase in the number of patients with seizures following the Great East-Japan Earthquake

In the afternoon of March 11, 2011, Kesennuma City was hit by the Great East-Japan Earthquake and a devastating tsunami. The purpose of this retrospective study is to document possible changes in the number of patients with distinct neurologic diseases seeking treatment following this disaster. Because of Kesennuma's unique geographical location, the city was isolated by the disaster, allowing for a study with relatively limited population selection bias. Patients admitted for neurologic emergencies from January 14 to May 5 in 2011 (n = 117) were compared with patients in the corresponding 16-week periods in 2008-2010 (n = 323). The number of patients with unprovoked seizures was significantly higher during the 8-week period after the earthquake (n = 13) than during the same periods in 2008 (n = 6), 2009 (n = 3), and 2010 (no patients) (p = 0.0062). In contrast, the number of patients treated for other neurologic diseases such as stroke, trauma, and tumors remained unchanged. To our knowledge, this is the first report of an increase in the number of patients with seizures following a life-threatening natural disaster. We suggest that stress associated with life-threatening situations may enhance seizure generation.

Cytosine-phosphate-guanosine-DNA induces CD274 expression in human B cells and suppresses T helper type 2 cytokine production in pollen antigen-stimulated CD4-positive cells

Co-stimulatory molecules are important for regulating T cell activation and immune response. CD274 [programmed death ligand 1 (PD-L1), B7-H1] has emerged as an important immune modulator that can block T cell receptor signalling. We have investigated whether PD-L1 and other co-stimulatory ligands could be expressed in human B cells stimulated by cytosine-phosphate-guanosine (CpG)-DNA. CpG-DNA strongly induced the co-inhibitory molecule ligand, PD-L1, of human B cells. Results show that nuclear factor-kappa B (NF-κB) signalling is involved directly in CpG-DNA-induced PD-L1 expression in human B cells. We sought to determine the effect of CpG-DNA-treated B cells on T helper type 2 (Th2) cytokine production in Cry j 1 (Japanese pollen antigen)-stimulated human CD4-positive cells from patients with seasonal allergic rhinitis caused by Japanese cedar pollen. CpG-DNA-treated B cells reduced Cry j 1-induced interleukin (IL)-5 and IL-13 production in CD4-positive cells. When the binding of PD-1 to PD-L1 was inhibited by PD-1-immunoglobulin (Ig), this chimera molecule reversed the previously described reductions in IL-5 and IL-13 production. In contrast, the CpG B-treated B cells increased both interferon (IFN)-γ and IL-12 production in the presence of Cry j 1-stimulated CD4-positive cells. CpG-DNA simultaneously reduced the expression of B7RP-1 [also known as inducible co-stimulator ligand (ICOSL), B7-H2] and the ligand of CD30 (CD30L). These results indicate that CpG-DNA induces co-inhibitory molecule ligand PD-L1 expression in human B cells and PD-L1 can suppress Th2 cytokine production in Cry j 1-stimulated CD4-positive cells, while CpG-DNA increased Th1 cytokine production and reduced the expression of co-stimulatory molecule ligands that can promote Th2 inflammatory responses.

Systemic pregabalin attenuates sensorimotor responses and medullary glutamate release in inflammatory tooth pain model

Our previous studies have demonstrated that application of inflammatory irritant mustard oil (MO) to the tooth pulp induces medullary glutamate release and central sensitization in the rat medullary dorsal horn (MDH), as well as nociceptive sensorimotor responses in craniofacial muscles in rats. There is recent evidence that anticonvulsant drugs such as pregabalin that influence glutamatergic neurotransmission are effective in several pain states. The aim of this study was to examine whether systemic administration of pregabalin attenuated glutamate release in the medulla as well as these nociceptive effects reflected in increased electromyographic (EMG) activity induced by MO application to the tooth pulp. Male adult rats were anesthetized with isofluorane (1.0-1.2%), and jaw and tongue muscle EMG activities were recorded by needle electrodes inserted bilaterally into masseter and anterior digastric muscles and into the genioglossus muscle, and also the medullary release of glutamate was assessed by in vivo microdialysis. Pregabalin or vehicle control (isotonic saline) was administered 30 min before the pulpal application of MO or vehicle control (mineral oil). Application of mineral oil to the maxillary first molar tooth pulp produced no change in baseline EMG activity and glutamate release. However, application of MO to the pulp significantly increased both the medullary release of glutamate and EMG activity in the jaw and tongue muscles for several minutes. In contrast, pre-medication with pregabalin, but not vehicle control, significantly and dose-dependently attenuated the medullary glutamate release and EMG activity in these muscles after MO application to the tooth pulp (analysis of variance (ANOVA), p<0.05). These results suggest that pregabalin may attenuate the medullary release of glutamate and associated nociceptive sensorimotor responses in this acute inflammatory pulpal pain model, and that it may prove useful for the treatment of orofacial inflammatory pain states.

Influence of beverage and food consumption on fluoride intake in Japanese children aged 3-5 years

This study was conducted to estimate the relative contribution of particular foods and drinks to dietary fluoride intake in 94 preschool Japanese children in low-fluoride areas. The mean daily fluoride intake from all beverages (548 +/- 162 g) was 0.108 mg (SD = 0.082), accounting for 37% of the total dietary fluoride; tea beverages showed the highest value, 0.093 mg (SD = 0.081), 32%. That from staple food and side dishes was 0.183 mg (SD = 0.146), 63%, followed by cereals (12%), fish (8%) and bean products (5%). In conclusion, the contribution of beverages excluding tea to dietary fluoride intake is small in Japanese children.

Three dogs under 2 years of age with heartworm caval syndrome

Heartworm caval syndrome (CS) occurred in three dogs under 2 years of age. A 23-month-old dog was recovered by surgical and medical treatments, but the other 2 dogs (15 and 21 months old) died. Necropsy demonstrated 12 heartworms in the 15-month-old dog and 8 worms in the 21-month-old dog. Histopathologically, pulmonary arterial embolism caused by dead worms and thrombi were observed in these cases. The findings suggested that CS could develop regardless of canine age and worm burden if pulmonary arterial embolism related to worm death or thrombus formation were induced.

Induction of heat shock protein (HSP)-70 in posterior cingulate and retrosplenial cortex of rat brain by dizocilpine and phencyclidine: lack of protective effects of sigma receptor ligands

The role of sigma receptors in the induction of heat shock protein (HSP)-70 by non-competitive N-methyl-Daspartate (NMDA) receptor antagonists (+)-MK-801 (dizocilpine) and phencyclidine (PCP) was studied. HSP-70 is induced in the posterior cingulate and retrosplenial cortex of rat brain 24 hours after a single administration of dizocilpine (1 mg/kg) or PCP (50 mg/kg). The induction of heat shock protein HSP-70 by dizocilpine or PCP was attenuated partially by pre-treatment with the antipsychotic drug haloperidol (3 mg/kg, i.p., 15 minutes previously). However, pre-treatment with high potent and selective sigma receptor ligands, 4-phenyl-4-(1-phenylbutyl)piperidine (4-PPBP, 3 mg/kg, i.p., 15 minutes previously) and N,N-dipropyl-2-[4-methoxy-3-(2-phenylethoxy)phenyl]-ethylamine monohydrochloride) (NE-100, 3 mg/kg, i.p., 15 minutes previously) did not alter the induction of HSP-70 by dizocilpine or PCP. These findings suggest that sigma receptors may not play a significant role in the induction of HSP-70 by non-competitive NMDA receptor antagonists dizocilpine and PCP, and that protective effects of haloperidol on induction of HSP-70 protein by dizocilpine or PCP may be due to other effect(s) except sigma receptors.

Transcription factors GATA-4 and GATA-6 during mouse and human adrenocortical development

Our earlier work implicates transcription factors GATA-4 and GATA-6 in the murine adrenal. We have now studied their expression during mouse and human adrenal development in detail. GATA-4 and GATA-6 mRNAs are readily detectable from embryonic day 15 in mouse and gestational week 19 in human adrenal cortex. In postnatal adrenal, GATA-4 expression is down-regulated, whereas GATA-6 mRNA and protein continue to be abundantly present. In a human adrenocortical cell line NCI-H295R, GATA-6 mRNA is up-regulated by cAMP. This cell line does not express GATA-4. Our findings suggest that GATA-6 expression is hormonally controlled, and required throughout adrenal development from fetal to adult age. GATA-4, on the other hand, may serve a role in fetal adrenal gene regulation.

Fluoride intake in Japanese children aged 3-5 years by the duplicate-diet technique

This study was conducted to determine the fluoride intakes in 94 preschool children aged 3, 4 and 5 (n = 30, 30, 34, respectively) residing in Yokkaichi, Mie Prefecture (< 0.16 ppm F water supply). The parents duplicated all the diets that their children ingested on 3 separate days during a 1-year period. The acid-diffusible fluoride in the diet was isolated by the acid-diffusion technique and measured with a fluoride electrode. The mean daily fluoride intakes from diet alone by children aged 3, 4 and 5 were 0.30 mg (n = 29, SD 0.19), 0.28 mg (n = 30, SD 0.19) and 0.30 mg (n = 34, SD 0.19), respectively. The total estimated mean values from diet and dentifrice were 0.35 mg (n = 29, SD 0.22, range 0.13-1.00), 0.33 mg (n = 30, SD 0.19, range 0.13-0.86) and 0.39 mg (n = 34, SD 0.18, range 0.18-1.01), respectively. It was concluded that the mean (+/-SD) total fluoride from diet and dentifrice in 3- to 5-year-old Japanese children was 0.35 +/- 0.19 mg/day (0.021 +/- 0.012 mg/kg body weight).