The factors that influence the risk of accidents during the replacement of gastrostomy catheters remain unknown and therefore have not yet been thoroughly investigated. We conducted a nationwide questionnaire survey of 415 rehabilitation-training facilities for the replacement of gastrostomy catheters. We received 221 valid responses. Among the catheter replacement methods submitted, the bumper button replacement method was the most widely chosen, comprising 40% of the valid responses. The measures used to prevent accidental erroneous catheterization included examination of the stomach contents, endoscopic examination of the stomach, and the detection of insufflation sounds, although these measures varied widely among the facilities. Fifty-one out of the 221 facilities that responded to the survey experienced various mishaps, of which 20 were due to erroneous catheterization. In approximately 40% of the facilities, there was no operative manual for the replacement nor was the patient's consent taken before performing the procedure. This investigation elucidates the risks involved in the replacement of gastrostomy catheters. This survey also suggests that the methods used for catheter replacement should be re-examined to prevent accidents during the replacement.

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The three-dimensional structure of thoracic and lumbar nerves was investigated in rats using Sihler's staining method. It was observed that the dorsal and lateral cutaneous nerves pierced the surface muscles to enter the subcutaneous tissue at a point 1-2 segments caudal to the base of the spinal nerve, while the ventral cutaneous nerves pierced the surface muscles 7 segments caudal to the base. The dorsal and lateral cutaneous nerves also ran more caudally, 2-3 and 2-4 segments, respectively, in the subcutaneous tissue. In addition, the tilt angles of spinal nerve rami lying against the transverse plane of the body trunk increased caudally, and the ventral rami showed a drastic increase in their tilt angle. Combined with our previous studies on dermatomes and sclerotomes, the present results imply that the innervation territory of the spinal nerve is shaped like a “deformed cone”, with the apex at the base of the spinal nerve and the lateral aspect expanding caudally. The stereoscopic structure of spinal nerve innervation territories may provide novel viewpoints for use in the diagnosis and treatment of disorders of the spine and spinal cord.

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Patients with focal hand dystonia demonstrate abnormally increased corticospinal excitability, which has been reported to be ameliorated, at least for a short term, with low frequency repetitive transcranial magnetic stimulation (rTMS). Transcranial direct current stimulation (tDCS), which is less costly and easier to apply than rTMS, is also known to modulate cortical excitability. Especially with cathodal tDCS, cortical excitability can be reduced. On the other hand, upper extremity splinting is also known to reduce dystonic symptoms by inhibiting abnormal movement. We therefore combined cathodal tDCS with finger splinting to treat focal hand dystonia in a 34-year-old man with traumatic brain injury who showed involuntary movement of his right fingers during writing and chopsticks use. After 5 days of cathodal tDCS sessions (1mA, 10min), he was encouraged to use interphalangeal joint splints for his thumb and index finger during these activities. We assessed computer-rated handwriting, reciprocal inhibition and intracortical inhibition before, 24 hours and 3 months after the 5-day tDCS sessions. Before the treatment, his flexor pollicis longus (FPL) and first dorsal interosseous (FDI) muscles showed 4Hz rhythmic hyperactivity during writing, and reciprocal inhibition at interstimulus intervals (ISI) of 20 and 100 ms were lost. Paired pulse TMS also revealed disinhibited short interval intracortical inhibition (SICI) at an ISI of 2 and 3 ms. The 5-day tDCS sessions reduced FPL and FDI EMG activities, and SICI and RI at 20 and 100 ms were also restored. Wearing the finger splints, these improvements were maintained at the 3-month follow-up. This case report is the first to demonstrate the possible long-term effects of tDCS combined with splinting for focal hand dystonia. It is supposed that splinting after tDCS plays an important role in making the tDCS aftereffects last longer.

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Present Status of the U.S.A. and Future Direction for Japan…Kiyokazu YOSHIDA 275

What is DPC?…Shinya MATSUDA 278

Correspondence to Diagnosis Procedure Combination/Prospective Payment System in the University Hospital…Kozo HANAYAMA 285

Correspondence to Diagnosis Procedure Combination/Prospective Payment System in the General Hospital…Hirotatsu TAKAHASHI 289

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