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Although multiple studies have investigated the mesenchymal stem and progenitor cells (MSCs) that give rise to mature bone marrow, high heterogeneity in their morphologies and properties causes difficulties in molecular separation of their distinct populations. In this study, by taking advantage of the resolution of the single cell transcriptome, we analyzed Sca-1 and PDGFR-α fraction in the mouse bone marrow tissue. The single cell transcriptome enabled us to further classify the population into seven populations according to their gene expression profiles. We then separately obtained the seven populations based on candidate marker genes, and specified their gene expression properties and epigenetic landscape by ATAC-seq. Our findings will enable to elucidate the stem cell niche signal in the bone marrow microenvironment, reconstitute bone marrow in vitro, and shed light on the potentially important role of identified subpopulation in various clinical applications to the treatment of bone- and bone marrow-related diseases.

Purpose Tissue engineering of esophagus is required for management of long-gap esophageal atresia (LGEA). Collagenous connective tissue membranes fabricated by in-body tissue architecture (iBTA), called biosheets, can repair esophageal defects and generate tissues similar to native esophagus. However, iBTA requires second-stage surgery because of heterotopic preparation of biosheets. Our aim was to develop orthotopic iBTA for primary engineering of the esophagus by interposing a tubular mold to the esophageal defect. Method The cervical esophagus of six rats was transected. An acrylic tube (internal diameter 2.6 mm, length 7.0 mm) was inserted and fixed between the ends of the upper and lower esophagus, and a 3 mm-long esophageal defect was created. Four weeks later, the rats were sacrificed for histological analysis. Results Postoperatively the rats could intake liquid food. After four weeks, the esophageal defects were filled with regenerated tissues. Histologically the new esophageal walls stained positive for collagen type I. The inner surfaces were covered with stratified squamous epithelium that expressed pan-cytokeratin. In only one of six rats, regeneration of muscular-like tissue was suggested by positive immunohistochemical staining for desmin. Conclusion Orthotopic iBTA can regenerate a substitute esophagus with esophageal epithelium and collagenous wall. This technique may be a novel treatment for esophageal atresia with gaps of various lengths including LGEA.

Secretory breast carcinoma constitutes the majority of breast cancers in children and young people less than 20 years of age. Noninvasive examination is particularly necessary for the diagnosis of breast carcinoma in children. Herein, we report a case of secretory breast carcinoma in a 6-year-old girl with psychomotor retardation. She was referred to our outpatient clinic for evaluation of a palpable mass in her left breast. A hard mass, rather than the increase in size typical of premature thelarche, was palpated. An excision biopsy was performed. Pathological findings revealed an invasive secretory breast carcinoma. We performed a retrospective review of the preoperative findings of this case, and compared it to the pathological diagnosis. Elastography, which can be performed without deep sedation or general anesthesia and without causing pain, resulted in a stiffness score of 4; however, the distinction between benign and malignant tumors on elastography, which is important to decide the intra-operative procedures, was not sufficient according to the Japanese breast cancer society clinical guidelines. This is the first report of secretory breast carcinoma in a child with a stiffness score determined by tissue elasticity imaging. A breast mass in a child with a high stiffness score of more than 4 on elastography should be referred for invasive diagnostic procedures, such as fine needle aspiration or excisional biopsy. According to our experience, an accurate preoperative diagnosis could be possible for malignant breast tumors in children. Such parameters as stiffness score on elastography are practical, noninvasive, and objective diagnostic tools for the accurate preoperative diagnosis of breast tumors in children.

Introduction: We devised a strategy for the fabrication of an ‘anatomy-mimicking’ cylinder-type engineered trachea combined with cartilage engineering. The engineered BIOTUBEs are used to support the architecture of the body tissue, for long-segment trachea (>5 cm) with carinal reconstruction. The aim of the present study was to fabricate an anatomy-mimicking cylinder-type regenerative airway, and investigate its applicability in a rabbit model. Methods: Collagen sponge rings (diameter: 6 mm) were arranged on a silicon tube (diameter: 6 mm) at 2-mm intervals. Chondrocytes from the auricular cartilage were seeded onto collagen sponges immediately prior to implantation in an autologous manner. These constructs were embedded in dorsal subcutaneous pouches of rabbits. One month after implantation, the constructs were retrieved for histological examination. In addition, cervical tracheal sleeve resection was performed, and these engineered constructs were implanted into defective airways through end-to-end anastomosis. Results: One month after implantation, the engineered constructs exhibited similar rigidity and flexibility to those observed with the native trachea. Through histological examination, the constructs showed an anatomy-mimicking tracheal architecture. In addition, the engineered constructs could be anastomosed to the native trachea without air leakage. Conclusion: The present study provides the possibility of generating anatomy-mimicking cylinder-type airways, termed BIO-AIR-TUBEs, that engineer cartilage in an in-vivo culture system. This approach involves the use of BIOTUBEs formed via in-body tissue architecture technology. Therefore, the BIO-AIR-TUBE may be useful as the basic architecture of artificial airways. Keywords: Anatomy-mimicking airway, Cylinder-type airway reconstruction, BIOTUBE, Engineered cartilage, BIO-AIR-TUBE

The lack of appropriate pediatric formulations is a global issue and information on acceptability is urgently needed to develop standard pediatric formulations. This study aimed to assess perceptions of acceptability of several oral dosage forms among pediatric patients at a community and a pediatric hospital in Japan and collected information about age-appropriate pediatric formulations, aiming to contribute to drug development promotion worldwide.A cross-sectional observational study was performed. A convenience sample of caregivers was recruited from available chain-owned retail pharmacies and inpatient pediatric units. The questionnaire was composed of 3 parts: (1) acceptability of the 5 dosage forms (tablets, capsules, powders, liquids, and orally disintegrating tablet) by age; (2) acceptability of dosage size, amount, and volume by age; and (3) the actual method of administration. Face-to-face interviews were conducted at 3 independent community pharmacies (324 parents) and tertiary care pediatric hospital wards (112 nursing staff). Acceptability scores and acceptable dosages were then determined. The survey was conducted from October 1 to December 1, 2017, for the hospital setting and November 1 to 30, 2017, for the outpatient setting.The acceptability of oral dosage forms was roughly similar to the matrix drafted by the European Medical Agency. Differences in perception of the powder forms between communities and hospitals were also observed, with the nursing staff perceiving powder as being acceptable from the neonatal period.The difference in caregivers' perception of the acceptability of oral formulations between Japan and Europe was small. The powder form was found to be more acceptable in Japan. Further intervention studies are needed to assess the preferred pediatric formulation worldwide.

OBJECTIVES For the technical management of tracheal anastomosis, developing new and simple methods is required to relieve anastomotic tension. This study aimed to investigate whether basic fibroblast growth factor (bFGF) only once injected immediately before anastomosis promotes cartilage regeneration at the tracheal anastomosis and whether the regenerated cartilage has the effect of reinforcing the anastomosis in a rabbit model. METHODS New Zealand white rabbits were anaesthetized, and the cervical trachea was exposed through a cervical midline incision, followed by resection of the 10th tracheal cartilage. The rabbits were categorized into 2 groups: the bFGF group (n = 6) and the control group (n = 6). In the former group, bFGF (25 μg) was administered into the submucosal layer of the cartilage using a 27-G needle immediately before tracheal anastomosis. The animals were sacrificed 4 weeks later. Histological, mechanical and biochemical evaluations were performed on this anastomosed trachea. RESULTS At 4 weeks of age, the anastomoses were spindle-shaped and displayed maximum diameter at the injection site compared with those in the control group. Histological evaluation showed that cartilage tissue had regenerated between the 9th and 11th tracheal cartilage rings. Tensile test showed that the anastomoses displayed a significantly high strain/stress ratio (P = 0.035). The collagen type II and glycosaminoglycan levels were significantly increased, and the collagen type I level was significantly decreased (P = 0.019, P = 0.013 and P = 0.045, respectively). CONCLUSIONS A new wound-healing concept of airway anastomosis could be provided by the results that single injection of bFGF regenerated tracheal cartilage in rabbits and strengthened the anastomosis by bridging the regenerated and well-matured cartilage. Further investigation of this method will lead to potential clinical applications for reinforcement of tracheal anastomoses.

Introduction The need for pharmacist-led antimicrobial stewardship programs (ASP) is increasing. Objective We performed a retrospective study to assess whether pharmacist-led ASPs can decrease the duration of treatment for uncomplicated gram-negative bacteremia among patients admitted in a community hospital. Methods This research was conducted at a 325-bed regional general hospital in Japan, from January 2013 to June 2015. There are no infectious diseases specialists affiliated with the hospital. The outcomes of the pharmacist-led ASP group, who received pharmacist intervention, and the control group, who did not receive pharmacist intervention, were compared. The study included patients aged 18 years or older who were diagnosed with gram-negative bacteremia. The pharmacist performed an antimicrobial time-out at 72 hours after blood culture collection and optimized treatment based on the patient's clinical response and test results. The primary outcome was the duration of antibiotic treatment. Results In total, 34 patients in the pharmacist-led ASP group and 32 in the control group were included in the final analysis. The median number of days of antimicrobial treatment was 8 (interquartile range [IQR]: 7-14) days in the pharmacist-led ASP group and 14 (IQR: 10-15) days in the control group. The number of days of antimicrobial treatment significantly reduced in the pharmacist-led ASP group (p < 0.001). The de-escalation rates were 11 (32.4%) cases in the pharmacist-led ASP group and 4 (12.5%) cases in the control group. Hence, the trend was higher in the pharmacist-led ASP group than in the control group (p = 0.08). Conclusion The pharmacist-led ASP reduced the number of days of antimicrobial therapy for uncomplicated gram-negative bacteremia among patients admitted in a community hospital without an infectious diseases specialist.

Objective:To determine whether carbapenem consumption andPseudomonas aeruginosaresistance rates can be used as benchmarks to compare and improve antimicrobial stewardship programs across multiple pediatric hospitals.Design:A prospective study.Setting and participants:Healthcare institutions in Japan with >100 pediatric beds.Methods:An annual survey of the total days of therapy (DOT) per 1,000 patient days for carbapenem antibiotics (meropenem, imipenem-cilastatin, panipenem-betamipron, doripenem) and susceptibility rates ofPseudomonas aeruginosato meropenem and imipenem-cilastatin from each institution was conducted over a 7-year period. Data were reported to the administration, as well as to the infection control team, of each institution annually.Results:Data were obtained from 32 facilities. The median total carbapenem DOT per 1,000 patient days was 16.6 and varied widely, with a range of 2.7 to 59.0. The median susceptibility to meropenem was 86.6%, ranging from 78.6% to 96.6%. We detected an inverse correlation between total carbapenem DOT versus susceptibility (r= – 0.36;P< .01). Over the 7-year period, the DOT per 1,000 patient days of carbapenem decreased by 27% from a median of 16.0 to 11.7 (P< .01). We also observed an improvement in susceptibility to meropenem from a median of 87% to 89.7% (P= .01) and to imipenem-cilastatin from 79% to 85% (P< .01). The decreases in the use of carbapenem were greater in institutions with antimicrobial stewardship programs led by pediatric infectious disease specialists.Conclusions:Antimicrobial use and resistance, targeting carbapenems andP. aeruginosa, respectively, can serve as benchmarks that can be utilized to promote antimicrobial stewardship across pediatric healthcare institutions.

Background Prosthetic patches can be used to repair large congenital diaphragmatic hernia defects but may be associated with infection, recurrence, and thoracic deformity. Biosheets (collagenous connective tissue membranes) have been used in regenerative medicine. We evaluated the efficacy of Biosheets in a rabbit model. Methods Biosheets were prepared by embedding silicone plates in dorsal subcutaneous pouches of rabbits for 4weeks. In group 1 (n=11), Gore-Tex® sheets (1.8×1.8cm) were implanted into a diaphragmatic defect. In group 2 (n=11), Seamdura®, a bioabsorbable artificial dural substitute, was implanted in the same manner. In group 3 (n=14), biosheets were autologously transplanted into the diaphragmatic defects. All rabbits were euthanized 3months after transplantation to evaluate their graft status. Results Herniation of liver was observed in 5 rabbits (45%) in group 1, 8 (73%) in group 2, and 3 (21%) in group 3. A significant difference was noted between groups 2 and 3 (P=0.017). Biosheets had equivalent burst strength and modulus of elasticity as native diaphragm. Muscular tissue regeneration in transplanted biosheets in group 3 was confirmed histologically. Conclusion Biosheets may be applied to diaphragmatic repair and replacement of diaphragmatic muscular tissue. Level of evidence Level III.

Antimicrobial stewardship programs (ASP) for oral antibiotics is still uncommon, despite the fact that oral antibiotics prescription accounts for 90% of total antibiotic consumption in developed countries. We introduced preauthorization and prospective audit and feedback (PAF) system on broad-spectrum oral antimicrobials as a part of ASP intervention from October 2015 in a tertiary children's hospital in Japan. Antimicrobial consumption and cost of targeted oral antimicrobials decreased from 11.1 days of therapy (DOT) per 1000 outpatient visits and 860,040 yen ($ 7167: 1 $ = 120 yen) to 1.9 DOT per 1000 outpatient visits and 142,200 yen ($ 1185) annually, respectively (p < 0.001). Interrupted time-series analysis showed that prescriptions for targeted antimicrobials decreased rapidly after initiation of preauthorization (p < 0.001). Prescriptions for non- targeted oral antimicrobial increased temporarily (p < 0.001), but a decreasing trend was found after the initiation (p < 0.001). In pre-intervention period, the main indications for using targeted antimicrobials were upper and lower respiratory infection, urinary tract infections, prophylaxis for medical procedures and otitis media, but only 21.4% of them were appropriate prescription. The appropriate prescription rate of post-intervention period increased to 58.5%. During the study period, the susceptibility pattern of major bacteria to these antimicrobials did not change. In conclusion, introduction of the preauthorization and PAF for selected oral antimicrobials decreased the antimicrobial use of both targeted and non-targeted antimicrobials. This intervention may be an effective method of ASP for other children's hospitals. (C) 2020 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

This study aimed to investigate whether intra-tracheal administration of basic fibroblast growth factor (b-FGF) promotes the growth of tracheal cartilage. Trachea of 4-week old mice were intubated and 2.5 μg b-FGF administered (Group 4) for periods from 1 to 5 days. Cervical tracheal outer diameter and tracheal ring length were compared in Group 1 (no intervention), Group 2 (tracheal intubation), Group 3 (intra-tracheal administration of distilled water) and Group 4, at 8 weeks of age. Outer diameter and tracheal ring length in Group 4 were also compared with that in Group 1 at 12 and 16 weeks of age. At 8 weeks of age, tracheal ring length with b-FGF administration for more than 4 days in Group 4 was significantly increased over that following 1-day administration. At 8 weeks of age, mean outer diameter and the mean tracheal ring length in Group 4 were significantly greater than in the other groups. Mean outer diameter and mean tracheal ring length were significantly greater in Group 4 than in Group 1 at 12 and 16 weeks of age. This study has shown that intra-tracheal administration of b-FGF enlarges the tracheal lumen.

Background Intratracheal injection of basic fibroblast growth factor (b-FGF) has been shown to enlarge the tracheal lumen 4 weeks after treatment. The objective of this study was to investigate the long-term effect of tracheal cartilage growth promotion by intratracheal injection of b-FGF. Materials and methods New Zealand white rabbits were classified into four groups to receive either distilled water alone (Group 1; n = 16; control), 40 μg (Group 2; n = 10), 100 μg (Group 3; n = 13), or 200 μg (Group 4; n = 16) of b-FGF dissolved in water. The treatment was injected into the posterior wall of the cervical trachea using a tracheoscope. The animals were sacrificed 4 or 12 weeks later. Results Four weeks after treatment, the mean luminal areas of tracheas for Groups 1, 2, 3, and 4 were 27.2, 25.6, 32.2, and 36.2 mm2, respectively. At 12 weeks, these were 29.3, 37.9, 42.5, and 56.0 mm2, respectively. The levels of glycosaminoglycan at 12 weeks were 93.9, 152.5, 123.2, and 210.6 μg/mg, respectively. At 12 weeks, the levels of type II collagen were 77.2, 133.1, 99.2, and 148.9 μg/mg, respectively. Conclusion Twelve weeks after a single injection of b-FGF, the mean luminal area of the trachea continued to increase.

A gelatin sponge with slowly releasing basic fibroblast growth factor (b-FGF) enhances chondrogenesis. This study investigated the optimal amount of b-FGF in gelatin sponges to fabricate engineered cartilage.b-FGF (0, 10, 100, 500, 1000, and 2000 μg/cm(3))-impregnated gelatin sponges incorporating β-tricalcium phosphate (β-TCP) were produced. Chondrocytes were isolated from the auricular cartilage of C57B6J mice and expanded. The expanded auricular chondrocytes (10×10(6) cells/cm(3)) were seeded onto the gelatin sponges, which served as scaffolds. The construct assembly was implanted in the subcutaneous space of mice through a syngeneic fashion. Thereafter, constructs were retrieved at 2, 4, or 6 weeks.(1) Morphology: The size of implanted constructs was larger than the size of the scaffold with 500, 1000, and 2000 μg/cm(3) b-FGF-impregnated gelatin sponges incorporating β-TCP at 4 and 6 weeks after implantation. (2) The weight of the constructs increased roughly proportional to the increase in volume of the b-FGF-impregnated scaffold at 2, 4, and 6 weeks after implantation, except in the 2000 μg/cm(3) b-FGF-impregnated constructs group. (3) Histological examination: Extracellular matrix in the center of the constructs was observed in gelatin sponges impregnated with more than 100 μg/cm(3) b-FGF at 4 weeks after implantation. The areas of cells with an abundant extracellular matrix were positive for cartilage-specific marker type 2 collagen in the constructs. (4) Protein assay: Glycosaminoglycan and collagen type 2 expression were significantly increased at 4 and 6 weeks on implantation of gelatin sponges impregnated with more than 100 μg/cm(3) b-FGF. At 6 weeks after implantation, the ratio of type 2 collagen to type 1 collagen in constructs impregnated with 100 μg/cm(3) or more b-FGF was higher than that in mice auricular cartilage.Gelatin sponges impregnated with more than 100 μg/cm(3) b-FGF incorporating β-TCP with chondrocytes (10×10(6) cells/cm(3)) can fabricate engineered cartilage at 4 weeks after implantation.

Tracheal cartilage reconstruction is an essential approach for the treatment of tracheal congenital abnormalities or injury. Here, we evaluated the use of allogeneic decellularized tracheas as novel support scaffolds. Six weaned pigs (4-week-old domestic males) were transplanted with allogeneic tracheal graft patches (three decellularized and three fresh tracheal scaffolds) onto artificial defects (approximately 15 × 15 mm). After 11 weeks, the tracheas were evaluated by bronchoscopy and histological studies. No pigs displayed airway symptoms during the observation period. Tracheal lumen restored by fresh graft patches showed more advanced narrowing than that treated with decellularized grafts by bronchoscopy. Histologically, fresh grafts induced typical cellular rejection; this was decreased with decellularized grafts. In addition, immunohistochemistry demonstrated regenerating foci of recipient cartilage along the adjacent surface of decellularized tracheal grafts. Decellularized allogeneic tracheal scaffolds could be effective materials for restoring impaired trachea.

Purpose Basic fibroblast growth factor (b-FGF) is a very effective growth factor that induces the proliferation of chondrocytes. This study aimed to investigate whether intra-tracheally-injected b-FGF solution promotes the growth of tracheal cartilage. Methods Group 1: 500μl of distilled water was injected at the posterior wall of the cervical trachea of New Zealand white rabbits by using a tracheoscope (n=5). Group 2: 100μg/500μl of b-FGF solution was injected at the posterior wall of the cervical trachea (n=5). Group 3: Biodegradable gelatin hydrogel microspheres incorporating 100μg/500μl of b-FGF solution were injected at the posterior wall of the cervical trachea (n=5). All animals were sacrificed 4weeks later, and the outer diameter and luminal area of the cervical trachea at the site of b-FGF injection were measured. Results The cervical tracheas in the two b-FGF injection groups were spindle-shaped and had a maximum diameter at the injection site. The median outer diameter of the cervical trachea in Groups 1, 2, and 3 was 7.3, 8.0, and 8.0mm, respectively, showing a significant difference among Groups 1, 2, and 3 (P=0.04). The median luminal area in Groups 1, 2, and 3 was 27.4, 29.4, and 32.1mm 2 , respectively. The ad hoc test showed a marginally significant difference only between groups 1 and 3 (p=0.056). Conclusion Intra-tracheal injection of slowly released b-FGF enlarged the tracheal lumen.

Objectives/Hypothesis Tracheoplasty using costal cartilage grafts to enlarge the tracheal lumen was performed to treat congenital tracheal stenosis. Fibrotic granulomatous tissue was observed at the edge of grafted costal cartilage. We investigated the junction between the native hyaline cartilage and the engineered cartilage plates that were generated by auricular chondrocytes for fabricating the airway. Study Design Controlled, prospecive study. Methods In group 1, costal cartilage from New Zealand white rabbits was collected and implanted into a space created in the cervical trachea. In group 2, chondrocytes from auricular cartilages were seeded on absorbable scaffolds. These constructs were implanted in the subcutaneous space. Engineered cartilage plates were then implanted into the trachea after 3 weeks of implantation of the constructs. The grafts in group 1 and 2 were retrieved after 4 weeks. Results In group 1, histological studies of the junction between the native hyaline cartilage and the implanted costal cartilage demonstrated chondrogenic tissue in four anastomoses sides out of the 10 examined. In group 2, the junction between the native trachea and the engineered cartilage showed neocartilage tissue in nine anastomoses sides out of 10. Conclusions Engineered cartilage may be beneficial for engineered airways, based on the findings of the junction between the native and engineered grafts. Level of Evidence 1a.

Tracheomalacia is a major cause of morbidity in conditions such as oesophageal atresia. However, symptoms usually improve with age. A more rapid growth of tracheal cartilage can be induced by basic-Fibroblast Growth Factor (b-FGF). This study aimed to investigate whether slow-release b-FGF could act as a novel treatment for tracheomalacia.Biodegradable gelatin hydrogel sheets incorporating 0.5, 5, or 50 μg/20 μl of b-FGF solution were inserted between the cervical trachea and esophagus of rats. No intervention was performed in rats in a control group. All animals were sacrificed 4 weeks later, and the luminal area of the cervical trachea and the thickness of the cartilage were measured.The mean luminal areas in the control group and in the b-FGF groups were 3.1, 3.2, 3.8, and 2.6mm(2), respectively, and showed a peak area at 5 μg of b-FGF. A significant difference was seen only between the control group and the b-FGF 5 μg group (p0.05). The mean thickness of the tracheal cartilage was 0.12, 0.13, 0.19, and 0.32 mm in the control and the b-FGF groups, respectively, and showed a dose-dependent increase, which was statistically significant between the b-FGF 5 μg or 50 μg groups and the control group (p0.01).This study showed that slow-release b-FGF enlarges the tracheal lumen and thickens the cartilage in a dose-dependent fashion.

Background/Purpose We have previously shown that intratracheal injection of slowly released (in gelatin) basic fibroblast growth factor (bFGF) significantly enlarged the tracheal lumen by a slight margin. This study aimed to investigate differences in tracheal cartilage growth by the intratracheal injection of bFGF doses in a rabbit model. Methods Water (group 1; n=7; control) or 100μg (group 2; n=8) or 200μg (group 3; n=8) of bFGF dissolved in water was injected into the posterior wall of the cervical trachea of New Zealand white rabbits using a tracheoscope. All animals were sacrificed four weeks later. Results The mean circumferences of cervical tracheas for groups 1, 2, and 3 were 18.8±0.83, 21.1±2.0, and 22.1±1.3mm, respectively. A significant difference was found between groups 1 and 2 (P=0.034) and groups 1 and 3 (P=0.004). The mean luminal areas of cervical tracheas for groups 1, 2, and 3 were 27.0±2.1, 32.2±4.8, and 36.3±4.6mm 2 , respectively. A significant difference was found between groups 1 and 3 (P=0.001). Conclusion Intratracheal injection of bFGF in the dose range used significantly promoted the growth of tracheal cartilage in a rabbit model. Levels of Evidence : Level II at treatment study (animal experiment).

Background Plasma citrulline has been reported to be a good indicator of intestinal functional volume in patients with intestinal dysfunction. We reconfirmed the facts and also investigated the dynamic changes of plasma citrulline in acute-phase patients with intestinal dysfunction. Methods We measured plasma citrulline in six patients with intestinal dysfunction who were in the acute and chronic phase for more than 6 months. Results Four patients out of six could be withdrawn from total parenteral nutrition, and their plasma citrulline level dynamically changed according to their intestinal states and finally increased up to 15 nmol/mL. Two patients, who could not be withdrawn from parenteral nutrition, showed very low levels of plasma citrulline throughout the treatment course (under 15 nmol/mL). Conclusion The cut-off level of plasma citrulline indicating permanent intestinal dysfunction may be 15 nmol/mL in our data. In the acute phase, plasma citrulline changed dynamically according to the intestinal state and may be a good indicator of fluctuating intestinal functions. Thus, although only a few patients were enrolled in this study, plasma citrulline may be a good indicator of stable-state as well as acute-unstable-state intestinal functions.

Ebara Turbomachinery Corporation In the process of manufacturing aluminum heat exchangers, they usually are brazed in the furnace filled with nitrogen below 20 ppm oxygen concentration. This paper proposes a new method to make the environment above. Firstly, the chamber (as a model of the furnace) is evacuated to a certain pressure. Secondary, it is filled with nitrogen gas. And then, it is evacuated again to 20 ppm. This method reduces both the amount of nitrogen gas consumption and the time until the oxygen concentration falls enough. Furthermore, this time is found to be the shortest when the initial degree of vacuum p₁ is the same as the secondary p₂., 本研究ではこの従来式の窒素置換法を改良するために，窒素置換専用の前室を設けて以下に記す手法で窒素置換を行い，その後ＮＢ炉内に投入する方法を提案する．その手法とは，窒素ガス噴入前に前室を一旦真空状態にした後に窒素を噴入するものである．ただし，要求される低酸素濃度を真空排気のみによって実現することは，ある程度の真空度と相応の時間，そしてＶＢ炉に匹敵する頑強な設備を必要とする．そこで本研究ではこの作業を2回に分けて行う新しい方法³⁾ （真空2回排気法）を採用することにした．まず前室内を比較的低い真空度の状態まで排気する（短時間で完了）．そしてその後窒素ガス噴入によって前室内を大気圧近くまで復圧し（噴入窒素量は炉容積程度），再度排気を行う．ここに至っては，前室内はすでに窒素ガスによって希釈されているので，やはり比較的に低い真空度までの排気でも容易に20 ppm以下の酸素濃度に到達可能である．2回目の排気の後にさらに窒素ガスを噴入し再び大気圧に戻せばロウ付けのための準備は完了である． この方法によれば真空排気の際の前室内圧力低下は1,000 Pa程度までであり，なおかつ直後には窒素によって大気圧まで復圧されるため低圧に晒される時間はきわめて短い．さらに前室は炉に比して小型に建造可能なため，ＶＢ炉のような高価な設備を用意する必要はない． 本稿では上述の真空2回排気法によって酸素濃度20 ppmに到達する時間を大幅に短縮できること，そして従来のＮＢ炉に比して窒素使用量も劇的に削減できることを模型実験の結果に基づいて報告する．さらに，この到達時間を最小にする条件についても考察を加える．

Background Antimicrobial stewardship programs (ASP) for oral antibiotics is limited, despite the fact that oral antibiotics account for 90% of total antibiotic consumption in developed countries. We aimed to analyze the effectiveness of ASP for oral antibiotics in a pediatric population. Methods We conducted a prospective study at a tertiary maternal and children fs hospital in Japan, consisting of 490 beds, with approximately 13,000 hospitalizations and 240,000 outpatient visits annually. Outpatient data on oral antimicrobial prescription, costs and proportions of resistant bacteria between 2013 and 2016 were analyzed. We conducted preauthorization and feedback as a means of intervention from October 2015 for targeted antimicrobials; vancomycin, linezolid, quinolones, faropenem, tebipenem pivoxil, polymyxin B. Antibiotic use density (AUD) was measured using days of therapy (DOT) /1000 visits. Interrupted time-series (ITS) analysis was performed to evaluate the effects of intervention. Results The main indications for use of targeted antimicrobials were urinary tract infections, pneumonia, and prophylactic administration in malignancy and were inappropriate in the majority prior to intervention. AUD and cost of targeted oral antimicrobials decreased from 11.0 DOT /1000 visits and 7,176 US dollars(USD) to 2.1 DOT/1000 visits and 1,665 USD, respectively (P < .001). ITS analysis showed that prescriptions for targeted antimicrobials decreased rapidly after initiation of preauthorization(-7.1 DOT /1000 visits; P < .001) (Figure 2-a). Prescriptions for non-targeted oral antimicrobial increased temporarily (+28 DOT/1000 visits; P < .001), but a decreasing trend was found after the initiation (P < .001) (Figure 2-b). During this study period, the susceptibility against quinolones did not change for E.coli, K.pneumoniae, and P.aeruginosa. Conclusion Introduction of the preauthorization system for selected oral antimicrobials decreased the AUD of both targeted and non-targeted antimicrobials. Disclosures N. Kinoshita, Standardization and dissemination of a community based network of infection control targeting children MHLW H29-SHINKOGYOSEI-IPPAN-002: Board Member, Salary; I. Miyairi, Standardization and dissemination of a community based network of infection control targeting children MHLW H29-SHINKOGYOSEI-IPPAN-002: Grant Investigator, Research grant

To disclose the influence of foreign body responses raised against a non-absorbable hydrogel consisting of tissue-engineered cartilage, we embedded human/canine chondrocytes within agarose and transplanted them into subcutaneous pockets in nude mice and donor beagles. One month after transplantation, cartilage formation was observed in the experiments using human chondrocytes in nude mice. No significant invasion of blood cells was noted in the areas where the cartilage was newly formed. Around the tissue-engineered cartilage, agarose fragments, a dense fibrous connective tissue and many macrophages were observed. On the other hand, no cartilage tissue was detected in the autologous transplantation of canine chondrocytes. Few surviving chondrocytes were observed in the agarose and no accumulation of blood cells was observed in the inner parts of the transplants. Localizations of IgG and complements were noted in areas of agarose, and also in the devitalized cells embedded within the agarose. Even if we had inhibited the proximity of the blood cells to the transplanted cells, the survival of the cells could not be secured. We suggest that these cytotoxic mechanisms seem to be associated not only with macrophages but also with soluble factors, including antibodies and complements.

A 1-year-old boy was admitted to our department with undescended testis on the left side of the body. Upon surgical exploration, a diagnosis of polyorchidism was made. The accessory proximal testis was removed and the distal testis underwent orchidopexy. Pathological findings revealed duplication of the vas deferens and epididymis but without an accessory testis. We then performed further intra-abdominal exploration in order to identify intra-abdominal testis arising from complete urogenital nonunion. We concluded that this represents the first documented case exhibiting duplication of the vas deferens and epididymis.

The number and types of minimally invasive surgical procedures being performed in children have increased exponentially in the last 15 years. Laparoscopic fundoplication is commonly performed for gastroesophageal reflux disease (GERD), although the population of patients who undergo this procedure is different in adults and children. In Japan, laparoscopic fundoplication has become a standard procedure, even for children with neurological impairment; however, its indications remain controversial. In this article we review the status of laparoscopic antireflux surgery for infants and children, looking at its indications, the procedures available, the complications, and the training required to perform the procedure safely and effectively.

Background: Infants with severe congenital anomaly often need to undergo operation followed by antibiotic therapy. As a result they inevitably acquire abnormal intestinal microbiota, which cause severe infections such as necrotizing enterocolitis. Also, intestinal function deteriorates and their nutritional state is very poor. In order to prevent these situations probiotic therapy is proposed as an effective supporting treatment. Probiotic therapy were therefore applied to infants with severe congenital anomaly as early as possible to ascertain its efficacy. Methods: As probiotics, two bacteria were used: Bifidobacterium breve Yakult and Lactobacillus casei Shirota. Probiotic therapy was used in four infants with severe congenital anomaly as early as possible after surgery. Their intestinal microbiota and physical growth were followed through the treatment course. Results: Two patients suffered from meconium peritonitis with ileal atresia. One patient was born with complex anomalies (omphalocele, bladder exstrophy, myelomeningocele). The fourth patient suffered from complete urorectal septum malformation. The intestinal microbiota of these four patients was first induced to be probiotic dominant and finally changed to commensal anaerobe dominant that was similar to normal intestinal microbiota. Pathogenic bacteria were seldom detected. The patients' physical growth was excellent despite short bowel and pulmonary hypoplasia. Conclusion: Probiotic therapy was effective in inducing probiotic dominant intestinal microbiota and normal intestinal microbiota in infants with severe congenital anomalies. As a result their intestinal absorptive functions were activated and severe infections were completely prevented. All of the infants grew well despite their physical disadvantages.

The performance of a Stirling engine depends significantly on performance of heat exchanger. The heat exchanger of a Stirling engine comprises a heater, a cooler, and a regenerator. The heater and cooler perform heat transferring from high and low external heat sources to working gas, while the regenerator absorbs heat from the working gas when the gas flows from heater to cooler, and releases heat during the reverse process. These auxiliary devices increase the weight of the engine and reduce its specific power. In this study, in order to improve the performance of the compact Stirling engine, a new heat exchanger(hereafter called the prototype heat exchanger) with a heater that reduces the energy loss from combustion gas, and a cooling system that uses fuel gas were developed. The performances of these systems were then compared with that of a conventional multi-tube heat exchanger. The prototype heat exchanger capable of reducing the heat loss in a heat exchanger via conbusting in a tube. Additionally, the weight of the prototype heat exchanger is lighter than that of a conventional multi-tube heat exchanger. The prototype heat exchanger is advantageous for reducing the engine weight and improving the specific power. Experiments conducted on the prototype heat exchanger installed on the engine showed excellent results and its superior performance.

Complete urorectal septum malformation sequence (URSMS) is usually a lethal anomaly that is characterized by urethral obstruction, imperforate anus, ambiguous genitalia, renal agenesis or dysplasia, and mullerian duct maldevelopment. This anomaly is thought to be caused by the cessation of urorectal septum migration toward the caudal cloacal membrane. Teratogenic factors or a genetic abnormality is postulated as the etiology. To date, only 4 patients with URSMS have survived the neonatal period; however, 2 of these infants died before the age of 1 year. We report the survival in a case with complete URSMS who had moderate pulmonary hypoplasia and preserved left renal function. The cloacal remnant wasdilated more than expected because the wall of the muscle layer was torn, perhaps in early fetal life, and timely placement of vesico-amniotic shunts prevented severe pulmonary hypoplasia caused by oligohydramnios.

Introduction We have designed an engineered graft fabricated from a biodegradable scaffold using chondrocytes and applied this construct to augment repair of tracheal stenosis. This study investigated the feasibility of using such tissue-engineered airways with autologous chondrocytes in a rabbit model. Material and Methods Chondrocytes were isolated and expanded from the auricular cartilage of New Zealand white rabbits, then seeded onto composite 3-layer scaffolds consisting of a collagen sheet, a polyglycolic acid mesh, and a copolymer (l-lactide/ ɛ -caprolactone) coarse mesh. The engineered grafts were implanted into a 0.5 × 0.8-cm defect created in the midventral portion of the cervical trachea. Gelatin sponges that slowly released basic fibroblast growth factor (b-FGF) were then placed on the constructs, which were retrieved 1 or 3 months after implantation. Results The biodegradable scaffold seeded with chondrocytes could maintain airway structure up to 3 months after implantation. Tracheal epithelial regeneration occurred in the internal lumen of this composite scaffold. Three months after implantation, staining of the sections showed cartilage accumulation in the engineered tracheal wall. Conclusion This composite biodegradable scaffold may be useful for developing engineered trachea. A gelatin sponge slowly releasing b-FGF might enhance chondrogenesis.

Background Collagenous connective tissue membranes (biosheets) are useful for engineering cardiovascular tissue in tissue engineering. The aim was to evaluate the use of biosheets as a potential tracheal substitute material in vivo in a rabbit model. Methods Group 1: Rectangular-shaped Gore-Tex (4×7mm) was implanted into a 3×6mm defect created in the midventral portion of the cervical trachea. Group 2: Rectangular-shaped dermis was implanted into a tracheotomy of similar size. Group 3: Biosheets were prepared by embedding silicone moulds in dorsal subcutaneous pouches in rabbits for 1month. Rectangular-shaped biosheets were implanted into a tracheotomy of similar size in an autologous fashion. All groups (each containing 10 animals) were sacrificed 4weeks after implantation. Main Results All materials maintained airway structure for up to 4weeks after implantation. Regenerative cartilage in implanted Biosheets in group 3 was confirmed by histological analysis. Tracheal epithelial regeneration occurred in the internal lumen of group 3. There were significant differences in the amounts of collagen type II and glycosaminoglycan between group 3 and group 1 or 2. Conclusion We confirm that cartilage can self-regenerate onto an airway patch using Biosheets.

Small-caliber synthetic grafts used for coronary bypass artery grafting are compromised by thrombogenicity and accelerated intimal thickening, resulting in early graft occlusion. Herein we describe the fabrication and physical properties of small-caliber blood vessels using decellularized porcine aortic segments. These vessels were further coated with human saphenous vein endothelial cells (HSVECs) for future clinical applications. Chemical staining of decellularized vessels showed that they preserved their native matrix architecture, including several collagen layers in between internal and external elastin layers. The burst pressure for the decellularized vessels was higher than 1,000 mmHg. HSVECs, seeded on the luminal side, adhered to the matrix and formed a uniform monolayer. HSVEC-seeded vessels produced prostaglandin I2 and released vasoactive agents in response to the calcium ionophore A23187. These results show that engineered blood vessels coated with the host endothelial cells possess morphologic and functional characteristics of human small-caliber vessels. Tissue-engineered vessels may potentially be useful clinically as vascular grafts.

Autologous and synthetic vessel grafts have been used as a vascular substitute for cardiovascular bypass procedures. However, these materials are limited by the availability of appropriate caliber autologous vessels, increased susceptibility to thrombosis and intimal hyperplasia following surgery. Electrospinning technology offers the potential for controlling composition, structure and mechanical properties of biomaterials. Vascular graft scaffolds have been fabricated using electrospun polymer blends of Type I collagen, elastin from ligamentum nuchae, and poly (d,l-lactide-co-glycolide). This study demonstrates improved electrospinning characteristics versus previous studies by increasing polymer concentration and adding PLGA to the polymer blend. Additionally, new in vitro biocompatibility and mechanical testing data is presented. The scaffolds possess tissue composition and mechanical properties similar to native vessels. The electrospun vessel matrix is biocompatible and does not elicit local or systemic toxic effects when implanted in vivo. This study demonstrates the promise of electrospinning as a fabrication process for a functional vascular graft for clinical use.