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We assessed the effect of high partial pressure of arterial carbon dioxide (PaCO2) due to pneumoperitoneum (PP) on growth (height/weight) and development (gross/fine motor function, receptive/expressive communication, and social interaction), by comparing outcome after portoenterostomy (PE) for biliary atresia (BA) using laparoscopic PE (LPE: n = 13) and open PE (OPE: n = 13) cases performed between 2005 and 2014. Our PE is based on Kasai’s original PE. All data were collated prospectively. Differences in duration of follow-up (LPE: 38.8 months; OPE: 38.1 months), jaundice clearance (LPE: 12/13 = 92.3 %; OPE: 9/13 = 69.2 %), survival with the native liver (LPE: 10/13 = 76.9 %; OPE: 9/13 = 69.2 %), incidence of cholangitis, hypersplenism, and incidence of esophageal varices were not significant. Mean intraoperative PaCO2 was significantly higher in LPE (LPE: 50.1 mmHg; OPE: 40.7 mmHg, p

There are few reports about postoperative outcome of penoplasty (PP). We present the results of mid- to long-term follow-up of PP performed for congenital megaprepuce (CMP). Data from 65 CMP cases treated by PP performed by a single surgeon from 2000 to 2014 were collected prospectively. All cases were treated using the technique reported by Cuckow (Pediatric surgery. Springer, Berlin, pp 543–554, 2006). Mean age at PP was 5.9 years (range 0.4–13.9). All cases presented as infants and some 12 cases (18.5 %) had PP when 10 or more years old. There were no intra- and postoperative complications. Mean duration of follow-up was 3.6 years (range 0.1–17.5). Duration of follow-up was 4 years or less in 48 (73.8 %), 5–9 years in 13 (20.0 %), and 10 or more years in 4 (6.2 %). While postoperative penile cosmesis was good in 63/65 (96.9 %) cases without scrotal deformity, 2/65 (3.1 %) had redundant penile skin excised upon the recommendation of the treating surgeon even though the patients and parents were unconcerned. Mid- to long-term follow-up of our PP cases shows that outcome is cosmetically acceptable and stable.

Ewing sarcoma (ES) of the bladder is extremely rare. Here we report the successful treatment of the youngest case of ES arising from bladder encountered to date and a literature review. A 10-year-old boy who presented with polyuria and lower abdominal swelling was found to have a 13 cm mass arising from the bladder localized to the center of the lower abdomen. Biopsy confirmed ES. Following chemotherapy, the mass shrank to 5 cm and was found to be localized to the right side of the bladder with invasion of the right vas deferens. One-third of the right side of the bladder and part of the right vas deferens were resected. No viable cancer cells were detected in the resected specimen, and the surgical margins were reported to be negative. The patient is currently well with no recurrence or metastases after 11 months. There are 12 cases of Ewings sarcoma arising from the bladder reported in the English literature; two cases in children. Our case will be the third pediatric case and the youngest.

Generally, open portoenterostomy (PE) involves a wide extended anastomosis and all sutures are deep [extended PE (EP)]. In contrast, the anastomosis in Kasai’s PE (KP), our modified open Kasai PE (MK), and our laparoscopic modified Kasai PE (lapMK) involve shallow suturing, especially at the 2 and 10 o’clock positions where the right and left bile ducts would be normally. We compared outcomes of 36 consecutive biliary atresia (BA) patients treated by three types of PE at a single institution during the period 2005–2014; EP (n = 13), MK (n = 11), and lapMK (n = 12). We compared age at PE, time taken to become jaundice-free (total bilirubin ≤1.2 mg/dL; JF time), proportion of JF subjects [JF ratio (JFR)], steroid dosage, incidence of cholangitis, postoperative liver function and CRP, presence of hypersplenism, requirement for liver transplantation (LTx), and JF survival with the native liver (JF+NL) as indicators of outcome. Patient demographics, steroid dosage, JF time, incidence of cholangitis, presence of hypersplenism, operating time, blood loss and postoperative biochemistry were similar for all groups. However, JFR was significantly higher for lapMK (100 %) versus EP (46.2 %) (p

Background The association of vaginal atresia (or Mayer–Rokitansky–Kuster–Hauser Syndrome) with imperforate anus is rare and can present significant diagnostic and therapeutic challenges. This study describes clinical characteristics, surgical treatment and outcomes in this group of complex children. Methods Records of 20 patients were retrospectively analyzed from two pediatric surgical centers. Results Five patients were excluded from the long-term analysis due to inadequate information, leaving long-term follow-up in 15 patients. Mean follow-up was 10 years (range 1–31.1 years). The diagnosis of vaginal atresia was made pre-operatively in 12 out of 15 patients, and in three patients it was identified during the anoplasty. The anorectal malformations were rectoperineal (N = 2), rectovestibular (N = 6), recto-bladder neck (N = 1) and imperforate anus without fistula (N = 6). Satisfactory surgical repair was performed in 13 patients, while one continues to stool through a low perineal fistula awaiting definitive surgery and another underwent a colostomy and mucous fistula. Delayed vaginal reconstruction was due to a failure to identify the problem prior to anoplasty (N = 3). Long-term results demonstrated that anorectal continence was much worse than initially appreciated, and many had associated urinary incontinence. Overall stooling score was far lower than in a separate group of children with imperforate anus without vaginal atresia ( Levitt and Pena, 2007 ). Conclusions Vaginal atresia with imperforate anus is a rare and an extensive pre-operative workup of females with imperforate anus must include assessment of vagina patency. Vaginal reconstruction and anorectal continuity can be performed in a variety of approaches, but long-term continence is often not optimal. We propose a pathway for management of this difficult genito-anorectal disorder.

Background In our previous studies, the outcome of high-risk ALL was still poor. In the present study, all children with ALL were classified into three groups and treated with a new regimen (AL90). Patients and Methods Between 1990 and 1996, 220 children with ALL, treated with the AL90 regimen, were classified into three risk groups: low, intermediate, and high: LR, IR, and HR, respectively. The protocol consisted of three- to five-drug induction, consolidation with intermediate-dose methotrexate and/or cytarabine, mercaptopurine and cyclophosphamide, four-drug intensification, and sequential maintenance therapies. Only intrathecal chemotherapy was used for CNS prophylaris in the LR group, whereas cranial irradiation was added for the IR and HR groups. Results The number of eligible patients was 91: LR group, 71: IR group, and 58: HR group. Complete remission (CR) was obtained in > 98% of the LR and IR groups, while only 88% achieved CR in the HR group. The 5-year event-free survival (EFS) rate was 67.4% in all patients: 70.4% in the LR group, 71.7% in the IR group, and 57.5% in the HR group. With respect to the previous study, EFS in the HR group who showed positive residual leukemia at 14 days was improved, whereas EFS in boys versus girls was significantly lower (48.8% : 85.7%, P = 0.02). Conclusions In high-risk ALL, the rate of induction failure was high and boys had a worse outcome, calling for improvements in induction therapy and a specific approach for boys. Med. Pediatr. Oncol. 37:10–19, 2001. © 2001 Wiley-Liss, Inc.

Content-Centric Networks (CCNs) promise to deliver content in a better way than today's Internet. In CCNs, efficient content delivery services can be achieved by using cache storage on routers. However, an effective caching scheme in CCNs is never established, because the communication method in CCNs differs from that in traditional networks. Therefore, we propose a selective caching scheme which only caches content likely to be used next. Furthermore, we show its effectiveness through simulations.

The evolution of various body plans results from the acquisition of novel structures as well as the loss of existing structures. Some novel structures necessitate multiple evolutionary steps, requiring organisms to overcome the intermediate steps, which might be less adaptive or neutral. To examine this issue, echinoderms might provide an ideal experimental system. A larval skeleton is acquired in some echinoderm lineages, such as sea urchins, probably via the co-option of the skeletogenic machinery that was already established to produce the adult skeleton. The acquisition of a larval skeleton was found to require multiple steps and so provides a model experimental system for reproducing intermediate evolutionary stages. The fact that echinoderm embryology has been studied with various natural populations also presents an advantage.

Although thoracoscopic lobectomy for severe bronchiectasis has been reported in children, this is the fi rst report of double lobectomy of the right middle and lower lobes performed using the video-assisted thoracoscopy in a 9-year-old girl. The post-operative course was uneventful and she is currently well after 18 months’ follow-up.Key words: Bronchiectasis, children, double lobectomy, video-assisted thoracoscopy

It is uncertain whether or not apoptosis is involved in the pathogenesis of primary biliary cirrhosis (PBC). The aims of this study were to assess the nuclear DNA fragmentation and expression of Bcl-2 in the biliary epithelial cells (BECs) and in the hepatocytes of PBC. Additionally, the effects of ursodeoxycholic acid (UDCA) on DNA fragmentation and Bcl-2 expression in PBC were evaluated. Liver tissue specimens from 35 PBC patients were examined by in situ nick-end labeling to detect any nuclear DNA fragments, and by immunohistochemistry for Bcl-2. Ten of these patients underwent a second liver biopsy after the treatment with UDCA. Sixteen histologically normal liver tissues and 17 chronic viral hepatitis C (CVHC) samples were chosen as controls. DNA fragmentation in BECs was more frequently found in PBC than in CVHC and more frequently than in the normal controls (both P < .05), and fragmentation in the hepatocytes of PBC more frequently than in normal controls (P < .01). Bcl-2 expression was more frequently found in both the BECs and hepatocytes of PBC than in the controls. UDCA significantly decreased the DNA fragmentation in BECs (P < .05) and the positivity for Bcl-2 in BECs (P < .01), although no significant decrease was found in hepatocytes. In conclusion, de novo Bcl-2 expression in hepatocytes of PBC was shown, and the increased nuclear DNA fragmentation and the Bcl-2 expression both in BECs and in hepatocytes may reflect apoptotic stress, although nuclear DNA fragmentation in BECs did not necessarily represent apoptosis. UDCA showed a potential effect of reducing nuclear DNA fragmentation in BECs.

To gain a better understanding of molluscan development and its relation to the evolution of their unique body plan, we performed a genomic survey of genes encoding transcription factors, such as Tbx, Fox, Ets, HMG, NFκB, bZIP, and C2H2 zinc finger proteins in the Japanese pearl oyster, Pinctada fucata. We annotated 133 transcription factor genes. Together with the orthologs of known deuterostome genes, we found several orphan genes in each class of transcription factor. Some possessed clear orthologs in other species of lophotrochozoans, while no counterpart genes were found in the deuterostomes or ecdysozoans. These observations suggest that a number of transcription factor genes are unique to lophotrochozoans, and thus additional research frontiers remain to be explored with regard to such transcription factors.

Packet losses significantly degrade TCP performance in high latency networks. To improve TCP performance in such networks, we proposed two methods to suppress the return of duplicate ACKs and to control minimum redundancy because FEC technology cannot work effectively when simply applied to TCP operation. Simulation evaluations show that the proposed methods enable higher throughput than the conventional methods, especially in high latency environments. In our future work, we will consider a scheme to more appropriately determine the appropriate redundancy level for network conditions and to more effectively recover lost packets in a real environment, such as where burst packet losses occur.

We report four cases of long-gap esophageal atresia (LGEA) treated with thoracoscopic esophagoesophagostomy (TEE) after sequential extrathoracic esophageal elongation (SEEE: Kimura’s technique). All initially had gastrostomy, then SEEE. The proximal end of the esophagus was introduced into the apex of the thorax under direct vision during TEE. Mean birth weight was 1.9 kg. Mean gestational age was 35.0 weeks (range 30–39); mean age at initial esophagostomy was 43.2 days (range 15–110); SEEE was performed for a mean of 3 times (range 2–4) at mean intervals of 5.3 months (range 2–10), with the upper esophageal segment lengthened by a mean of 2.1 cm each time (range 1.1–3.5). Mean age and weight at TEE were 22.3 months and 9.8 kg, respectively. Gap was initially 4.5 vertebrae (range 4–5). Mean operating time was 9.6 h. TEE was successful in 3; 1 required thoracotomy, then re-anastomosis after 11 months of anastomosis leakage; 2 cases with post-TEE anastomosis leakage were treated conservatively. Postoperatively, all cases required fundoplication and esophageal dilatation (2, 3, 5, 8 times, respectively). At mean follow-up of 3.6 years, 2 eat normally and 2 eat minced food. TEE after SEEE appears to be a feasible option for treating LGEA.

To compare open repair (OR) with thoracoscopic repair (TR) for congenital diaphragmatic hernia (CDH) in neonates.Twenty-four neonatal CDH cases diagnosed prenatally or within 6 h of birth at our institute from 2002 to 2012 with mild pulmonary hypertension managed without inhaled nitric oxide, were studied. OR was routine until 2006 (n = 14; L:R = 12:2) and TR became routine in 2007 (n = 10; L:R = 10:0). All subjects had identical management.Gestational age at birth: OR 37.4 ± 1.6 vs. TR: 38.3 ± 1.1 weeks (p = 0.10); birth weight 2,636 ± 490 vs. 2,887 ± 429 grams (p = 0.20); preoperative A-aDO(2): 308 ± 200 vs. 331 ± 195 mmHg (p = 0.79); and operating time (min): 161 ± 42 vs. 194 ± 76 (p = 0.27). In TR, intraoperative cardiopulmonary status was stable, intraoperative hemorrhage was significantly less (4.8 ± 6.0 vs. 1.1 ± 0.1 grams; p = 0.038), wound cosmesis was excellent without surgical site infections, while, maximum postoperative CRP (2.0 ± 1.5 vs. 1.5 ± 1.1 mg/dL; p = 0.30), commencement of enteral feeding (6.9 ± 2.8 vs. 5.6 ± 2.8 days; p = 0.27), and length of postoperative hospitalization (36 ± 22 vs. 34 ± 12 days; p = 0.66) were improved, but not significantly. One OR case required surgery for intestinal obstruction.Thoracoscopic repair appears to be as effective as OR for treating selected cases of CDH in neonates, with excellent wound cosmesis.

Laparoscopically assisted anorectoplasty (LAARP) was expected to achieve better fecal continence than conventional procedures. However, the issue of which approach is better remains controversial. We compared outcomes between the conventional procedure and LAARP in male infants with rectoprostatic urethral fistula.Institutes belonging to the Japanese Study Group of Anorectal Anomalies (JSGA) were invited to participate. Subjects were male infants with rectoprostatic urethral fistula treated by the conventional approach (abdominoperineal pull-through and PSARP) or LAARP between 2000 and 2006. Medical charts and operative records were reviewed retrospectively.Eighty-one patients (conventional: 36, LAARP: 45) were enrolled from 15 centers. In both groups, the mean Kelly score was 5. The total score of the scoring system was newly developed by the Japanese Study Group of Anorectal Anomalies. Follow-up Project (5-15 points) was 10.7 and 12.1 in the conventional group and the LAARP group, respectively (p=0.07). The incidence of failed rectoanal anastomosis, mucosal prolapse, and anal stenosis was comparable in both groups. Posterior urethral diverticula were detected on cystourethrograms in 7% and 11% (p=1.0) and on MRI in 0% and 34% (p=0.02) of the conventional and the LAARP groups, respectively. Overall, 94% of diverticula were asymptomatic.Fecal continence and complication rates after LAARP were comparable to those observed after the conventional method. Posterior urethral diverticula were detected more frequently after LAARP.

Retroperitoneoscopic nephrectomy (R-neph) is still not generally favored by pediatric surgeons for various reasons, including lack of experience of retroperitoneal anatomy compared with pediatric urologists, concern about long operative times, and related complications.We compared nephrectomies/heminephrectomies planned, performed, and managed by five senior pediatric surgical trainees (SPST) under the supervision of a board-certified pediatric surgeon (BCPS) (A.Y.) using four-trocar retroperitoneoscopy (R-neph) (n=11) with conventional open nephrectomy and heminephrectomy (O-neph) (n=20) performed by 4 BCPS.O-neph comprised 14 nephrectomies and 6 upper pole nephrectomies; R-neph comprised 9 total nephrectomies and 2 upper pole nephrectomies. Mean age and mean weight at nephrectomy were not statistically different. Mean operating time (MOT) was 137 (range, 85-290) minutes in O-neph versus 197 (116-341) minutes in R-neph. MOT for the first 5 R-neph cases was 249 minutes versus 153 minutes for the last 6 cases. Mean blood loss was 17 (range, 1-55) mL in O-neph versus 10.3 (2-40) mL in R-neph. One R-neph case required conversion to O-neph. There were no transfusions and no intraoperative complications. Two partial heminephrectomy patients (one O-neph and one R-neph) developed transient urinoma postoperatively that resolved conservatively. Mean duration of postoperative bed rest was 1.0 day in O-neph versus 0.6 days in R-neph. Differences in mean postoperative fentanyl requirement (O-neph, 21.5 [10-40] μg/kg; R-neph, 4.1 [0-20] μg/kg) and duration of nonsteroidal anti-inflammatory suppository usage (O-neph, 2.3 [0-5] days; R-neph, 0.9 [0-2] days) were significant (both P.05). Full oral feeding was resumed after a mean of 1.6 (1-2) days in O neph and 1.2 (1-2) days in R-neph.R-neph was safely performed by SPST, and results were comparable to those with O-neph performed by BCPS.

The effectiveness of pull-through for Hirschsprung's disease is dependent on accurate identification of normoganglionic bowel in intraoperative biopsy specimens. We report 2 cases of patchy innervation of pull-through bowel in children with Hirschsprung's disease only identified by circumferential biopsying. Case 1 was an 8-month-old boy. During laparoscopy-assisted transanal endorectal pull-through, extra biopsies of bowel were taken circumferentially, 2 cm proximal to the level of normoganglionosis confirmed by laparoscopic colon biopsies. Aganglionosis was found at 3 o'clock, suggesting that bowel innervation at this level was patchy. Circumferential biopsies were performed a further 2cm proximally, and all sites were normoganglionic. This level was used for pull-through with excellent outcome. Case 2 was a 27-day-old boy. Similarly, extra biopsies were taken circumferentially, 2cm proximal to the level of "normoganglionosis" as indicated by conventional biopsying. Normoganglionosis was found only at 3 o'clock, while all other sites were hypoganglionic. A further series of circumferential biopsies was performed 2 cm proximally and hypoganglionosis was still identified, but only at 6 o'clock. Circumferential biopsies were repeated another 2cm proximally, and all sites were normoganglionic. We recommend circumferential biopsies be performed routinely to prevent bowel with patchy innervation from being used for pull-through and possibly causing postoperative bowel dysmotility in a subgroup of Hirschsprung's disease patients.

Multi-hop wireless networks have attracted much attention because of their flexibility and deploy ability. However, we have previously shown that communication stability in multi-hop wireless networks is degraded by a congestion propagation problem that occurs among neighbor APs. To prevent congestion propagation and enable stable communication, we proposed QMTR (Queue Management with Transmission Record) as a buffer management scheme. We have shown that this scheme allows sufficiently stable communication in a steady state. In this study, we consider a more realistic environment that includes transient states. Through simulation evaluation, we show that the scheme enables sufficiently stable communication even under a transient state in multi-hop wireless networks.

We describe a case of a 15 year old boy who developed acute megakaryoblastic leukemia (AMKL) while receiving treatment with human growth hormone (hGH) for idiopathic growth hormone deficiency (GHD). He was diagnosed as having idiopathic GHD and given hGH from December 1991. The examination of his peripheral blood showed mild pancytopenia 2 months before the start of the hGH therapy. Since January 1992, paleness of the skin, general fatigue and fervescence progressed gradually. In February 1992, because of the occurrence of acute leukemia, administration of hGH was discontinued. Judging from the results of surface marker analysis of the blast cells, the patient was diagnosed as having AMKL. He was treated with chemotherapy for acute non-lymphoblastic leukemia from March 1992. A complete remission was obtained after 4 weeks of treatment. The chemotherapy was completed in July 1993. He remains in complete remission 26 months after diagnosis. This case suggests the importance of hematological examination and, when there is any abnormality which is not caused by GHD, such as pancytopenia, more detailed medical examinations (for example bone marrow examination) are necessary.

We evaluated the efficacy and toxicity of aclarubicin for acute non-lymphocytic leukemia (ANLL) refractory to daunorubicin in childhood. Twenty-four patients were treated with aclarubicin and prednisolone with or without 6-mercaptopurine and behenoyl-cytosine arabinoside daily for 5 to 14 days. Of 21 evaluable patients, 14 (67%) responded: 12 obtained complete remission and 2 partial remission. The median time to reach complete remission was 37 days (range, 16 to 60 days), and the median duration of complete remission was 5.5 months (range, 2 to 41 months). The cumulative dose of anthracycline administered before the study was not considered significant for the response. The only major complication was severe bone marrow suppression; infectious episodes occurred in 14 patients (58%) and three died of sepsis and/or bleeding. The observed non-hematologic toxicities included hematuria, an elevation of serum amylase, nausea/vomiting, and angitis. In addition, one patient showed abnormal cardiac function. Aclarubicin is therefore considered a highly active drug for remission reinduction of previously treated children suffering from ANLL with an acceptable toxicity.

Over the course of evolution, the acquisition of novel structures has ultimately led to wide variation in morphology among extant multicellular organisms. Thus, the origins of genetic systems for new morphological structures are a subject of great interest in evolutionary biology. The larval skeleton is a novel structure acquired in some echinoderm lineages via the activation of the adult skeletogenic machinery. Previously, VEGF signaling was suggested to have played an important role in the acquisition of the larval skeleton. In the present study, we compared expression patterns of Alx genes among echinoderm classes to further explore the factors involved in the acquisition of a larval skeleton. We found that the alx1 gene, originally described as crucial for sea urchin skeletogenesis, may have also played an essential role in the evolution of the larval skeleton. Unlike those echinoderms that have a larval skeleton, we found that alx1 of starfish was barely expressed in early larvae that have no skeleton. When alx1 overexpression was induced via injection of alx1 mRNA into starfish eggs, the expression patterns of certain genes, including those possibly involved in skeletogenesis, were altered. This suggested that a portion of the skeletogenic program was induced solely by alx1. However, we observed no obvious external phenotype or skeleton. We concluded that alx1 was necessary but not sufficient for the acquisition of the larval skeleton, which, in fact, requires several genetic events. Based on these results, we discuss how the larval expression of alx1 contributed to the acquisition of the larval skeleton in the putative ancestral lineage of echinoderms.

The evolution of the echinoderm larval skeleton was examined from the aspect of interactions between skeletogenic mesenchyme cells and surrounding epithelium. We focused on vascular endothelial growth factor (VEGF) signaling, which was reported to be essential for skeletogenesis in sea urchin larvae. Here, we examined the expression patterns of vegf and vegfr in starfish and brittle stars. During starfish embryogenesis, no expression of either vegfr or vegf was detected, which contrast with previous reports on the expression of starfish homologs of sea urchin skeletogenic genes, including Ets, Tbr, and Dri. In later stages, when adult skeletogenesis commenced, vegfr and vegf expression were upregulated in skeletogenic cells and in the adjacent epidermis, respectively. These expression patterns suggest that heterochronic activation of VEGF signaling is one of the key molecular evolutionary steps in the evolution of the larval skeleton. The absence of vegf or vegfr expression during early embryogenesis in starfish suggests that the evolution of the larval skeleton requires distinct evolutionary changes, both in mesoderm cells (activation of vegfr expression) and in epidermal cells (activation of vegf expression). In brittle stars, which have well-organized skeletons like the sea urchin, vegfr and vegf were expressed in the skeletogenic mesenchyme and the overlying epidermis, respectively, in the same manner as in sea urchins. Therefore, the distinct activation of vegfr and vegf may have occurred in two lineages, sea urchins and brittle stars.

We assessed continence after scope-assisted anorectovaginoplasty (SARVP) for female anorectal malformation (FARM). Five FARM cases were assessed; cases 1 and 2: cloacal malformation; case 3: urogenital sinus, and rectovestibular fistula (RF); case 4: RF, absent vagina, and sacral anomaly; case 5: covered cloacal exstrophy. Treatment was SARVP in all cases, with perineal vaginoplasty (case 1), vagina pull-through (PT) similar to Georgeson’s colon PT (case 2), and the use of the native RF/cloaca channel as a vagina (cases 3–5). Continence was assessed pre and postoperatively. SARVP was performed in the lithotomy position without repositioning. Mean age at surgery was 3.2 (1.7–5.5) years. Current mean age: 8.8 years (range 7.5–12.2). Mean follow-up: 5.7 years. Preoperative continence: fecal: all had stomas; urinary: cases 1 and 2: continent; cases 3–5: incontinent. Postoperative continence: fecal: cases 1–3: continent; case 4: incontinent; case 5: awaiting stoma closure; urinary: cases 1 and 2: continent; cases 3 and 4: incontinent; case 5: continent (intermittent catheterization). Fetal continence evaluation questionnaire (CEQ) scores for cases 1–4 were 7.5, 9, 10, and 2 (maximum score 10, mean 7.1). Scope assistance improves visualization, thus pelvic sphincter dissection/division is minimized with less detrimental impact on postoperative continence.

We reviewed 24 consecutive cases of prenatally or immediately postnatally diagnosed left-sided congenital diaphragmatic hernia (CDH) to evaluate pulmonary artery (PA) size as an indication for thoracoscopic repair (TR). CDH repair is planned once echocardiography confirms improvement in pulmonary hypertension. TR is chosen if cardiopulmonary status is stable more than 10 min in the decubitus position in the neonatal intensive care unit (NICU) under conventional mechanical or high frequency oscillatory ventilation (HFOV) with/without nitric oxide (NO) and the patient appears likely to tolerate manual ventilation during transfer to the operating room. Otherwise open repair (OR) is performed in NICU. Proximal right PA (RPA) and left PA (LPA) diameters measured at birth were assessed with respect to the type of repair. 10/24 had TR and 14/24 had OR. TR cases had significantly larger RPA/LPA diameters (3.52 ± 0.23 vs. 3.10 ± 0.56 mm, p

Streaming media delivery services over the Internet have spread rapidly, but further traffic growth may degrade the quality of streaming services due to congestion and packet loss events. As a result, content playback quality can be degraded and the waiting time for playback can be increased. In this paper, we propose a transparent caching scheme using advanced relay nodes for streaming services. This scheme can alleviate traffic congestion on networks and overloading on the streaming servers. We show the effectiveness of the scheme through simulation evaluations.

To determine if follow-up by consultant pediatric surgeons (CPS) affects morbidity due to incarceration (INC) in children with indirect inguinal hernia (IH). We educate parents so they can identify possible INC and advise them to attend our emergency department anytime for immediate review by on-call CPS. We reviewed 3,493 cases of IH by grouping them according to age at diagnosis: neonatal (G1; n = 96), 2–3 months (G2; n = 331), 4–6 months (G3; n = 118), 7–12 months (G4; n = 193), and over 12 months (G5; n = 2,755). Data per group were: mean gestational age (weeks): 32.1, 38.0, 36.4, 37.4, 38.7; mean birth weight (g): 1,645, 2,736, 2,471, 2,769, 2,930; mean age at elective hernia repair (HR) (months): 11.3, 4.9, 10.1, 12.9, 56.5; mean weight at elective HR (kg): 6.8, 6.4, 7.3, 9.1, 17.4; mean duration from diagnosis to elective HR (months): 10.9, 3.1, 6.3, 3.6, 3.0; mean follow-up: 6.7 years. Overall, INC occurred in 203/3,493 during follow-up. Incidence per group was: G1: 4/96, G2: 62/331, G3: 6/118, G4: 47/193, G5: 84/2,755. All INC were reduced manually without complications. HR complications occurred in 7/3,493 (0.2%). With CPS follow-up, INC can be managed without morbidity, allowing elective HR to be performed later with fewer complications.

Snodgrass tubularized incised plate urethroplasty (SUP) is versatile and has good cosmesis. However, postoperative meatal/neourethral stenosis (M/N-S) is common enough for some surgeons to add a dorsal inlay graft (DIG) harvested from the inner prepuce and sutured to cover the longitudinal midline incision of the urethral plate. This is the first formal assessment of the effectiveness of DIG for preventing M/N-S.We reviewed the medical records of 100 consecutive SUP cases performed by a single surgeon between 2003 and 2010 comparing SUP + DIG (S + D group, n = 50) with SUP - DIG (S - D group, n = 50). Mean follow-up was 3.6 years. Data were analyzed statistically using the χ(2), 2-way ANOVA, and Mann-Whitney tests, with P.05 considered significant.Severity of hypospadias and type of SUP were similar. Mean age at SUP was 3.3 years in S + D and 3.6 years in S-D (P = NS). There were 4 complications in the S + D group: urethrocutaneous fistula (n = 3) and neourethral stenosis without diverticulum (n = 1). There were 15 complications in the S-D group : meatal stenosis (n = 2), neourethral stenosis with or without diverticulum (n = 6), urethrocutaneous fistula (n = 7) (P.01). M/N-S was significantly less in the S + D group (1 vs 8; P.05).We strongly recommend that DIG be performed routinely during SUP.

Laparoscopic Kasai portoenterostomy (LKPE) is generally regarded to have a poorer outcome than open Kasai portoenterostomy for the surgical treatment of uncorrectable biliary atresia. We will describe our LKPE as the only center using laparoscopy to perform Kasai portoenterostomy in Japan.For our LKPE, a 5-mm trocar is placed in the epigastrium in addition to conventional trocar placement. A Ligasure device is inserted through this additional trocar to seal portal vein branches at the porta hepatis draining into the caudate lobe, instead of hook diathermy that is used universally elsewhere because there is an unacceptably high risk for lateral thermal injury to microbile ducts. We minimize porta hepatic microbile duct injury during anastomosis between the Roux-en-Y jejunum and the liver parenchyma around the transected biliary remnant by not suturing where the original right and left bile ducts were present and making sutures deliberately shallow but deep enough to prevent leakage. Our anastomosis is more central to the porta hepatis, like the original Kasai, compared with "extensive lateral dissection" commonly performed elsewhere in Japan. The length of the Roux-en-Y jejunal limb should be individualized, not predetermined to be 30, 40, or 50 cm as is common practice; the jejuno-jejunostomy should fit naturally into the splenic flexure, otherwise the redundant limb may become tortuous as the patient grows, causing bile stasis and possible cholangitis.Our LKPE can be performed safely and successfully with encouraging outcome.

In recent years, microblogging is popular among people and informal communication becomes important in various communities. Therefore, a number of Web communication tools are developed to facilitate informal communication. In this paper, focusing on microblogging service, Twitter, we develop a user recommendation engine which extracts latent topics of users based on followings, lists, mentions and RTs. This recommendation algorithm is based on Latent Dirichlet Allocation (LDA) and KL divergence between two users' latent topics. This algorithm hypothesizes that the users have latent connection if the distance calculated by KL divergence is short. Additionally, we performed an experiment to evaluate the effectiveness of the algorithm, and this showed that there is correlation between the distance and user's preference obtained through questionnaire.

摘脾術は脾機能亢進症などの疾患で行われ,摘脾後の免疫異常は種々報告されているが, IgG subclassの異常の報告はない.症例は15歳男子.摘脾後1ヵ月のIgG subclassではIgG 2がIgG 1よりも増加し, 6ヵ月後に正常なIgG subclassとなった症例を経験したので報告する.10歳のときに多発性骨〓腫のために骨移植を受ける.その頃より血小板が徐々に減少しだし12歳頃より鼻出血,紫斑が多くなり,血小板数は6×104/μlであった.入院後,脾腫が急速に増大し,血小板が減少したため脾機能亢進症と診断し摘脾術を施行した.摘脾前のIgGは559 mg/dl, IgGのsubclassはIgG 1 350 mg/dl, IgG 2 181 mg/dlであったが,摘脾1ヵ月後にはIgG 1 637 mg/dl IgG 2 895 mg/dlとIgG 2がIgG 1より増加していた.摘脾3ヵ月後でもIgG 2がIgG 1より増加していたが,摘脾6ヵ月後にはIgG subclassは正常になった.この原因としてIgG subclass産生細胞,形質細胞の分布が臓器により一様でないためと考えられた.

We assessed ductal plate malformation (DPM) as a prognostic factor for mid-/long-term outcome in post-hepatoportoenterostomy (HPE) biliary atresia patients.Of 78 cases of HPE performed between 1989 and 2009, biopsy specimens were available for 43. Cytokeratin 19 was used to identify DPM and preoperative status, postoperative serum total bilirubin, time taken to become jaundice-free, duration of jaundice-free period, steroid usage, incidences of cholangitis, bile lakes, and varices, and requirement for reoperation and liver transplantation were compared.DPM was detected in 21/43 (48.8%) subjects [DPM-positive (DPM+)]. Differences were identified for maximum postoperative serum total bilirubin: DPM+ (12.28 ± 1.00 mg/dL) versus DPM-negative (DPM-) (9.67 ± 0.71 mg/dL) (P 0.05) and total steroid usage: DPM+ (98.3 ± 11.8 mg/kg) versus DPM- (83.4 ± 15.9 mg/kg) (P = NS). However, total steroid dose in jaundice-free cases was significantly higher in DPM+ [75.3 ± 10.0 mg/kg (n = 14) vs. 48.1 ± 6.4 mg/kg (n = 19); P 0.05)]. There were no differences for complications. Mean duration of follow-up was significantly shorter for DPM+ (60.9 ± 38.4 vs. 113.8 ± 56.9 months; P 0.05).Postoperative total bilirubin was higher in DPM+ cases, thus higher doses of steroids were required. However, DPM+ did not appear to influence the incidence of complications mid-/long-term.

Ectopic pancreas is of little clinical significance. We report a case of ectopic pancreas in a 2-year-old girl presenting as a heterogeneous solid submucosal tumor of the posterior wall of antrum proximal to the pylorus, treated by distal gastrectomy and Billroth I reconstruction. We reviewed 15 cases in the English literature.

Purpose The piebald lethal mouse with a deletion of endothelin-B receptor gene (EDNRB) is a model for Hirschsprung's disease (HD), whereas the SOX10 gene is vital for the development of intestinal neural crest–derived cells. Recently, we created a SOX10 transgenic mouse with intestinal neural crest–derived cells visible with enhanced green fluorescent protein (VENUS), that is, SOX10-VENUS + /EDNRB sl/sl to investigate intestinal innervation in HD. Methods SOX10-VENUS + /EDNRB sl/sl (n = 30) were compared with wild-type littermates as controls (EDNRB s/s , n=30). Mice were killed on days 3, 7, or 12 of age. The entire colorectum was excised, fixed with 4% paraformaldehyde, and examined using fluorescence microscopy alone without staining. Results In normoganglionic colorectum from controls, a grid network of nerve fibers/glial cells was visualized that connected smoothly with extrinsic nerve fibers running along the colorectal wall. In aganglionic colorectum from SOX10-VENUS + /EDNRB sl/sl mice, there was no grid network and more extrinsic nerve fibers than controls that invaded the colon wall becoming elongated with branching fibers. Normoganglionic colon from controls and SOX10-VENUS + /EDNRB sl/sl mice appeared the same. Innervation patterns did not change over time. Conclusion This is the first time for abnormal enteric innervation in aganglionic colon in a model for HD to be visualized without staining.

Aim The anorectal angle (AA) influences defecation after pull-through (PT) for imperforate anus (IA). We compared postoperative AA and continence after Georgeson's laparoscopy-assisted colon PT (GPT) and Pena's posterior sagittal anorectoplasty (PSARP) for high/intermediate-type IA. Methods We reviewed 33 high/intermediate-type IA cases (20 GPTs and 13 PSARPs) prospectively. All had colostomy initially as neonates. Anorectal angle was measured as the angle between the rectum and the anal canal on barium enema. A fecal continence evaluation questionnaire (FCEQ) consisting of 5 parameters (frequency of defecation, staining/soiling, perianal erosion, anal shape, and requirement for medication; maximum score=10) was evaluated in 28 cases (15 GPTs and 13 PSARPs) followed up for more than 3 years. Results Mean age at PT was similar (6.6 months for GPT and 6.3 months for PSARP; P = not significant). There was no significant difference in mean AA. The FCEQ scores for GPT were generally higher throughout the study and significantly better from 3 years postoperatively ( P Conclusions We are the first to confirm that effective AA similar to PSARP can be achieved after GPT, although FCEQ would suggest that GPT has less detrimental functional impact.

Anal canal duplication (ACD) is an extremely rare congenital intestinal anomaly. There are not many reports in the English literature, with just a few from each institution. The aim of this study was to describe the clinical characteristics, surgical treatment, and outcome of ACD in pediatric cases at a single institution. The medical records of ACD patients we treated from 1988 to 2009 were reviewed retrospectively. There were ten cases, all females. Nine were asymptomatic without any history of perianal infection, identified only incidentally at routine check-up although one case had severe periproctal abscess. Mean age at diagnosis was 6 months (range 0–47 months). Concurrent pathology present were meningocele and presacral mass in one, presacral mass in one, and renal hypoplasia in one. In all cases, an extraneous perianal orifice opening in the midline posterior to the native anus was present, but in one case it was only identified at surgery because it had closed secondary to severe inflammation preoperatively. All had preoperative radiologic investigations, such as magnetic resonance imaging (MRI), barium contrast studies, and fistulography. Mean age at surgery was 14 months (range 1–48 months). All underwent surgical removal of the anal canal duplication, eight through a perineal approach and two through a posterior sagittal approach, depending on the length of the duplicated anal canal and the presence of concurrent anomalies. Histopathology of the excised anal canals showed squamous epithelium in all cases. The postoperative course was uneventful in all cases and all are well without complications at mean follow-up of 9.1 years (range 5–19 years). This is the largest series of ACD at a single institution reported to date. For the clinician faced with an extraneous perianal orifice located posteriorly in the midline with respect to the native anus, ACD should be suspected. The treatment of choice in children is complete excision (perineal/posterior sagittal approach), even if asymptomatic. Morbidity is minimal, and outcome is excellent.

A chloromethylated reaction was performed on the surfaces of polysulfone ultrafiltration hollow fibers and their derivative membranes, i.e., triethylaminated, ethylenediaminated, and acethylated fibers, were prepared. The modified fibers have a 30–60% insoluble region in chloroform, whereas nonmodified fibers can be dissolved in the chloroform. It is suggested that the insoluble parts of the fibers are highly cross-linked due to the high degree of chloromethylation. The modified fibers showed a 50–98% rejection of polyethylene glycol 6000 at a feed concentration of 0.5 wt %, except for the triethylaminated fibers, which gave a negative rejection from −91 to −96%. It was found that the modified segments significantly influenced the rejection behavior of the solutes. Absorption of bovine serum albumin on the ethylenediaminated fibers at pH 7.1 was estimated from permeation measurements to be less than that of the other modified and nonmodified fibers. This effect is attributed to the hydrophilic surface of the ethylenediaminated fibers.

1. 1. Arsenobetaine-containing growth media (ZoBell 2216E and a solution of inorganic salts) were incubated with suspended substances as a source of marine microorganisms. 2. 2. The degradation of arsenobetaine to inorganic arsenic was shown in the inorganic salts medium, being found for the first time with respect to the microorganisms occuring in them. 3. 3. Trimethylarsine oxide and dimethylarsinic acid were also shown as metabolites in both the media. 4. 4. These results suggest the microbial degradation of arsenobetaine in the water column.

症例は血友病BでHIV陽性の17歳男性.臨床症状と胸部X線所見(空洞とcoin lesion)より肺結核を疑われたが,ツベルクリン反応と喀痰の抗酸菌培養はともに陰性であった.患者喀痰中よりDNAを抽出し,結核菌の19KDa遺伝子領域をpolymerase chain reaction法を用いて増幅,電気泳動したところ,標準結核菌株のDNAと同じ311 base pairsの位置に陽性バンドを認めた.患者の症状, X線所見は,抗結核剤による治療により改善した.本法は,結核の早期診断,とりわけ免疫不全に随伴する場合の診断に有用と思われる.

Introduction We report a novel technique to measure the length of the rectourethral fistula (RUF) in male patients with high-/intermediate-type imperforate anus during laparoscopically assisted anorectal pull-through (LAARP) to prevent incomplete excision. Method During LAARP for RUF in 5 male patients (mean age, 4.6 months; prostatic in 3, bulbar in 2), the RUF was dissected carefully close to the urethra and opened; and a fine catheter with 10-mm calibrations was inserted by the laparoscopic surgeon until it was seen to emerge at or near the verumontanum by another surgeon performing cystoscopy. The laparoscopic surgeon then measured the distance from the point where dissection was ceased at the rectal end to the urethral orifice. The RUF was dissected free from the prostate for exactly this length, tied, and excised; and colon pull-through was performed to finish LAARP. Result Rectourethral fistulae ranged from 5 to 15 mm and were much longer than expected. All dissections were uncomplicated without any injury to the urethra, and postoperative courses were unremarkable. At mean follow-up of 11 months, urination is normal in all without evidence of residual fistula. Conclusion Knowing the exact length of the RUF facilitates safe and complete excision in an otherwise blind situation.

Hepatoblastoma originating in the caudate lobe is extremely rare, and resection is technically challenging. The aim of this study was to report our experience of complete resection of hepatoblastoma originating in the caudate lobe and review the literature. A 12-month-old boy was admitted for investigation of an upper abdominal mass. Imaging studies showed an irregularly lobulated 8-cm solid tumor in the left lobe of the liver. Serum alpha-fetoprotein was 67,700 ng/mL. This tumor was diagnosed as hepatoblastoma (PRETEXT II) and chemotherapy (3 courses of CDDP and ADR) was performed. After chemotherapy, the tumor had shrunk to a resectable size and its origin in the caudate lobe could be determined. Left hepatic lobectomy with en bloc resection of the caudate lobe was performed. Total blood loss was 10 mL, and the operation lasted 9 h. His postoperative course was uneventful. Preoperative chemotherapy facilitated complete resection by left hepatic lobectomy with total excision of the caudate lobe.

To achieve more effective and diverse services in emerging communication environment, the Internet has to provide more advanced capabilities; e.g., changing access terminals used for communication without disconnection is desirable. However, the current Internet architecture cannot realize such flexible communication. Therefore, a new network architecture concept has been proposed to enable flexible communication including dynamically changing access terminals during communication. Although this concept enables session migration, connection control methods are also needed to achieve effective migration. In this paper, we propose two kinds of connection controlmethods for session migration between access terminals. Furthermore, we evaluate the performance of the proposed methods through simulations and discuss a suitable connection control technique for session migration.

Group-oriented communication services have become more attractive due to diversifying demands of Internet users. In such emerging applications, information shared or exchanged by users in a group should be quickly and reliably delivered to other group members. However, the current Internet architecture is difficult to accommodate these applications efficiently. Therefore, a novel network architecture concept has been proposed to achieve group-oriented communication. Although this concept enables such communication, intelligent connection management schemes are also needed to improve the efficiency of network resource use. In this paper, we propose a session-based mechanism for efficient group communication. Furthermore, we show the effectiveness of the proposed scheme by means of simulations.

Multihop Wireless Networks (MWNs) are expected to expand the area of wireless access networks, which consist of multiple access points in the area of a wireless LAN and connect these access points with wireless links. However, the MWNs still have many issues to provide good quality of service. For example, it is not clear about traffic characteristics over the MWNs. In this paper, therefore, we investigate the characteristics of MWNs based on the congestion propagation between wireless routers reported in wired networks.Furthermore, we show the impact of the congestion propagation on the network performance in various network parameters by means of simulations.

Streaming media delivery services over the Internet have been rapidly spread. Growth of these traffic causes serious problems in terms of quality degradation of service in a near future. Therefore, in this paper, we propose a streaming media caching scheme on advanced relay nodes placed inside networks in order to achieve efficient streaming media delivery. The proposed scheme can alleviate traffic congestion on the networks and overload on the streaming servers. Furthermore, we show a potential and effectiveness of the proposed scheme through simulation evaluations.

Total parenteral nutrition (TPN) results in intestinal mucosal atrophic changes due to an absence of enteral nutrition; however, the mechanisms responsible for this are not fully understood. It has been shown that bone morphogenetic protein (BMP) activation inhibits intestinal epithelial cell (EC) proliferation. Therefore, we hypothesized that the BMP pathway could be upregulated by TPN. To address this, we randomly assigned mice to receive TPN or to be enterally fed (control) for 7 d. Mucosal EC isolates were harvested from the entire length of small intestine for RNA and protein measurements. Full-thickness, mid-small bowel was processed for histological examination. TPN increased the abundance of BMP2, BMP4, and BMP type II receptor at the RNA and protein levels. Phosphorylation of Smad1, Smad5, and Smad8 also was greater in the TPN group than in the control, which helped to confirm activation of this pathway. Interestingly, the TPN and control groups did not differ in the mRNA expression of the extracellular soluble bmp antagonists, noggin, gremlin, chordin, or follistatin. Compared to the control group, the expression of c-Myc (cellular myelocytomatosis) mRNA was lower, whereas the level of p21(WAF1/CIP1) was greater, in the TPN group. Because the BMP family may function through suppression of Wnt-beta-catenin signaling, this pathway was also examined. mRNA expression of Wnt 3, Wnt5a, and the Wnt receptor Lrp5 were lower in the TPN group compared to controls. The results suggest that the BMP signaling pathway may be involved in the development of intestinal mucosal atrophy due to TPN administration.

Background We have previously shown that angiotensin converting enzyme-inhibitor (ACE-I) improved colonic inflammation and apoptosis in a dextran sodium sulfate (DSS)-induced colitis model. This study attempted to determine whether ACE-I could prevent the development of colonic fibrosis. Methods Colitis was induced in C57BL/6 mice with 2.5% DSS water for 7 days, followed by 7 days without DSS (fibrosis development). Study groups: Control (naive or non-treated), DSS+Placebo (polyethylene glycol (PEG), and DSS+ACE-I (using enalaprilat and PEG which are not absorbed through intact mucosa). Placebo and ACE-I were delivered daily via transanal route. Colonic mucosal fibrosis and inflammation were evaluated based on histological findings and cytokine expression. Results Transanal administration of ACE-I/PEG dose-dependently decreased the severity of fibrosis and pro-inflammatory cytokine expression. We next investigated if ACE-I acted on the TGF-β/Smad signaling pathway as a mechanism of this anti-fibrosis action. Results showed a significant down-regulation of TGF-β1 expression; as well, downstream signaling of the Smad family, known to mediate fibrosis, showed a decline in Smad 3 and 4 expression with ACE-I/PEG. Conclusion ACE-I/PEG is effective in preventing colonic fibrosis and pro-inflammatory cytokine expression in a DSS colitis model, most likely by down-regulating the TGF-β signaling pathway. ACE-I/PEG may be a potential new option for treating inflammatory bowel disease.

We introduce one more layer of indirection between application and transport layers for building new types of applications in future networks with some slight modifications on the current Internet architecture. In this layer, end-to-end transport flows are identified by the pairs of source-destination host ID, port number and protocol, and some transport flows among multiple terminals associated with one specific application can be grouped and managed as "session.'' This layer can provide the common framework for realizing various types of applications such as group communication and session mobility and so on. Thus we will show the concept and the structure of this new layer architecture in detail. Moreover, we explain the collaboration of this new layer and "association layer'' proposed earlier to flexibly handle application flows in the environment of multiple terminals with multiple network interfaces.

The traditional virtual private network (VPN), which provides best effort or static bandwidth allocation services, does not support bursty Internet traffic well. As a way of supporting bursty traffic, a VPN provider can offer minimum throughput assurance (MTA) service to customers. MTA service provides higher throughput predictability than best effort VPN service. Although there are many proposed network architectures for MTA service, certain parameters should be decided offline as provisioning. The difficulty in such provisioning is to meet the minimum throughput requirements in any active state matrices. We propose a provisioning algorithm that uses nonlinear programming for MTA service. We also quantitatively evaluate our algorithm and its performance.

The aim of this study was to report on laparoscopy-assisted gastropexy in a child with situs inversus, asplenia, and major cardiac anomaly.A 15-month-old boy presented with a sudden onset of epigastralgia, nonbilious vomiting, and severe abdominal distention. After a nasogastric tube decompression of the stomach, symptoms resolved and an upper gastrointestinal contrast study confirmed situs inversus and asplenia. Computed tomography showed hepatic symmetry. Major cardiac anomalies (e.g., single atrium, single ventricle, common atrioventricular valve, and pulmonary atresia) were also present and had been treated elsewhere by a Blalock-Taussig shunt operation, the Glenn procedure, and pulmonary artery plasty. To prevent recurrent gastric volvulus, an anterior gastropexy procedure was performed laparoscopically. The patient's weight at the time of surgery was 8.1 kg, and the operating time was 65 minutes. Cardiopulmonary status was stable during insufflation and throughout the laparoscopic procedure. Postoperative recovery was uneventful, and the patient was allowed oral fluids 1 day after surgery and an unrestricted diet on day 2. A Fontan procedure was performed 18 months later, and our patient is now 6 years old and well--with no recurrence of gastrointestinal symptoms.This is the first report about the successful application of laparoscopy for performing a gastropexy procedure in a child with gastric volvulus, situs inversus, major cardiac anomaly, and asplenia.