Simulation-based training for determination of brain death by pediatric healthcare providers.

BACKGROUND: Low competency for determination of brain death (BD) and unfamiliarity with Japanese BD (JBD) criteria among pediatricians were highlighted in previous nationwide studies. Because the JBD criteria were amended in 2010 to allow organ donation from pediatric brain-dead donors, we created a 2-day training course to assess knowledge and improve skill in the determination and diagnosis of pediatric BD. METHODS: The course consisted of two modules: a multistation round session and a group discussion session, and was bookended by a before and after 20-question test. In the multistation round session, participants rotated between stations staffed by expert faculty members. For hands-on skill development, we used the Sim Junior 3G™ simulation mannequin (Laerdal Medical, Wappingers Falls, NY, USA) for structured simulations. In the group discussion session, we implemented simulation-based role playing to practice decision making in prepared scenarios of complicated clinical situations. We investigated the participants' impressions of the course by self-scoring and questionnaires. RESULTS: Of 147 pediatric healthcare providers from multiple specialties who participated in this course, 145 completed the entire process. The course was evaluated in three aspects with self-scoring and questionnaires: (1) value (4.58 ± 0.64; range 1-5); (2) time schedule (2.40 ± 0.61; range 1-3); and (3) difficulty (2.89 ± 0.43; range 1-5). Finally, participants scored the entire course program (9.64 ± 1.69; range 1-11). Various positive feedbacks were obtained from a total of 93 participants. Post-test scores (83.6 %) were significantly higher than pre-test scores (62.9 %). CONCLUSION: This simulation-based course represents an effective method to train pediatric healthcare providers in determining BD in Japan and may improve baseline knowledge of BD among participants.

Isolation and identification of cancer stem cells from a side population of a human hepatoblastoma cell line, HuH-6 clone-5.

PURPOSE: It has been thought that the persistence of even a small number of tumor cells in the body may increase each tumor cell in a similar manner and may allow the disease to proceed. However, only a few percent of such tumor cells exist in cancerous tissue. They are called "cancer stem cells (CSCs)". If an alternative method of annihilating CSCs is found, it will greatly deter relapse and metastasis. We attempted to identify and separate CSCs in hepatoblastoma aiming to develop a new therapy for hepatoblastoma. METHODS: The side population (SP) method was used as an indicator when extracting the CSC candidate group from the hepatoblastoma cells. The SP cells and non-SP cells were studied for tumourigenesis. RESULTS: Although tumors were formed when SP fraction cells were inoculated into mice, tumor formation was not observed in non-SP cells. SP cells had higher tumor formation ability compared to non-SP cells. CONCLUSION: Cancer stem-like cells were separated by the SP fraction method from hepatoblastoma cells. The in vivo experiment proved that SP fraction cells inoculated into mice were self-replicated, and the existence of cancer stem-like cells was identified.

Acute scrotum caused by vasitis with abscess formation in children with lower urological anomalies.

OBJECTIVES: The major causes of acute scrotum include testicular torsion, torsion of an appendix testis, and epididymo-orchitis. Recently, we experienced rare cases of acute scrotum caused by vasitis. Such a condition has not been previously reported in the literature so we summarize our patients with acute scrotum and discuss the pathogenesis of these rare cases. METHODS: Thirty-two pediatric patients were admitted to our institutions with a diagnosis of acute scrotum between 1997 and 2008. The average age of the patients was 7.1 years. We summarize and review the clinical and pathologic features of 2 patients with vasitis with abscess formation. RESULTS: The causes of acute scrotum included epididymitis, testicular torsion, and vasitis, among others. Testicular torsion was initially suspected in 23 of the patients. Twenty-three patients underwent emergency surgery, among whom 9 received orchidectomies. The initial diagnosis differed from the final diagnosis in 20 patients (62.5%). Two patients were diagnosed with vasitis. Both underwent emergency operations under a putative diagnosis of testicular torsion, and both were found to have hard tumorlike lesions in the scrotal portion during the surgery. These same 2 cases also suffered from lower urological anomalies, namely, hypospadias, posterior urethral valve, and Müllerian duct remnant. CONCLUSIONS: Based on our experience, we propose that lower urological anomalies predispose children to vasitis and subsequent abscess formation. Pathologic conditions of this type have to be considered as potential causes of acute scrotum.

The proton pump inhibitor inhibits cell growth and induces apoptosis in human hepatoblastoma.

PURPOSE: In normal physiology, a vacuolar-type proton pump (V-ATPase) maintains an intracellular acid microenvironment in lysosome, endosome, and other endomembrane systems. Cancer cells overexpress V-ATPase compared with normal cells, and disturbances of the acid environment are thought to significantly impact the cancer cell infiltration and growth. Bafilomycin A1 (Baf-A1) is a specific inhibitor of the proton-pump inhibitor (PPI) V-ATPase. Neoplastic cells are reportedly more sensitive to Baf-A1 than normal cells, and the difference between the susceptibility to Baf-A1 in normal cells and that in cancer cells may become a target in the cancer therapy. With this in mind, we used cells of hepatoblastoma, the cancer type accounting for 80% of all childhood liver cancers, to investigate the effects of Baf-A1 as an inducer of cancer cell apoptosis and inhibitor of cancer cell reproduction METHODS AND RESULTS: Electron microscopy showed significant morphological change of the hepatoblastoma cells of the Baf-A1-treated group compared with hepatoblastoma cells of the Baf-A1-free group. The rate of the apoptotic cell increased, and cell reproduction was inhibited. Moreover, the analysis of hepatoblastoma cells using the gene Chip gene expression analysis arrays showed that three of the 27 V-ATPase-related transcripts (ATP6V0D2, ATP6V1B1, and ATP6V0A1) were more weakly expressed in the Baf-A1-treated cells than in the Baf-A1-free cells. In normal human hepatic cells, on the other hand, the inhibition of cell growth of the Baf-A1-treated cells was negligible compared to that of the cells without Baf-A1 treatment. The result of apoptotic cell detection by morphological observations and flow cytometry revealed that Baf-A1 inhibits hepatoblastoma cellular reproduction by inducing apoptosis. On the other hand, the Baf-A1-conferred inhibition of cell growth was negligible in normal human hepatocytes CONCLUSION: The V-ATPase inhibitor Baf-A1 has been proven to selectively inhibit the reproduction and induce the apoptosis of hepatoblastoma cells without adversely influencing normal hepatic cells. With these effects, V-ATPase inhibitors may hold promise as therapeutic agents for hepatoblastoma. Given that three V-ATPase-related genes (ATP6V0D2, ATP6V1B1, and ATP6V0A1) were more weakly expressed in the hepatoblastoma cells of the Baf-A1-treated group than in the Baf-A1-free cells, drug development targeting V-ATPase gene of hepatoblastomas is expected.

Suppression of proinflammatory cytokine production in macrophages by lansoprazole.

Macrophages (MPs) produce increased levels of proinflammatory cytokines in Crohn's disease; these cytokines are thought to play a central role in the occurrence of the disease. Biologics are currently available for anti-cytokine therapy, but treating intestinal inflammation through direct suppression of proinflammatory cytokine production could be more effective. P-ATPase inhibitors have been reported to be anti-inflammatory, and these inhibitors might suppress the production of MP proinflammatory cytokines. In this study, we examined the effect of two types of ATPase inhibitors on the expression patterns of typical proinflammatory cytokines. Peritoneal MPs from 6- to 8-week-old mice were cultured for 48 h in the presence of lansoprazole (P-ATPase inhibitor), bafilomycin A(1) (V-ATPase inhibitor), or the control solvent dimethylsulfoxide. The MPs were then examined for cytokine expression by quantitative real-time polymerase chain reaction (PCR), and culture supernatants were examined for cytokine production with a multiplex assay in a suspension array system. The possible existence of P-ATPase mRNA in MPs was explored using reverse-transcriptase PCR. P-ATPase mRNA was not detected in MP cells. However, all examined proinflammatory cytokines decreased significantly in their mRNA and protein expression in the lansoprazole-treated group. Conversely, bafilomycin A(1) increased the levels of these cytokines. Lansoprazole might be useful for the treatment of inflammatory bowel diseases (IBDs), including Crohn's disease, as it suppresses the production of relevant MP proinflammatory cytokines. However, because P-ATPase was not detected in MPs, the mechanism is unclear and remains to be studied further in an IBD animal model.

Chest wall mesenchymal hamartoma associated with a massive fetal pleural effusion: a case report.

Abstract We report on an extremely rare chest wall mesenchymal hamartoma associated with a massive fetal pleural effusion. Prenatal ultrasound examination demonstrated a heterogeneous mass in the right thorax associated with a massive pleural effusion and right lung compression at 29 weeks of gestation. The patient underwent pleuroamniotic shunting at 30 weeks and was delivered at 33 weeks by cesarean delivery secondary to fetal distress. After management of the respiratory distress and evaluation of the mass, surgery was performed at day of life 8. Histological examination confirmed the diagnosis of a chest wall mesenchymal hamartoma.

Anorectal agenesis with a rectourethral fistula diagnosed in an adult: report of a case.

We report an unusual case of anorectal agenesis with a rectourethral fistula diagnosed in a 48-year-old man. The patient presented after noticing hematuria, although he had been aware of urinary leakage from his colostomy with occasional fecal urine for about 4 years. He had had a double-barrel colostomy created soon after birth for an imperforate anus, with revision at the age of 4 years to correct a prolapse of the stoma, but his malformation had never been repaired. We performed a physical examination, which did not reveal a perineal fistula, but urethrocystography demonstrated high anorectal agenesis with a rectourethral fistula. Thus, we resected the rectourethral fistula and created an end-colostomy. The patient had an uneventful postoperative course, and was discharged in good health on postoperative day 19. To our knowledge, this is the oldest patient to be diagnosed with anorectal agenesis and undergo resection of a rectourethral fistula.

No incidence of port-site recurrence after endosurgical procedure for pediatric malignancies.

Port-site recurrence (PSR) following laparoscopic procedures has been an unpredictable complication in adult cancer patients; however, no data exist about this phenomenon in the pediatric field. The aim of this study was to determine whether PSR, following endosurgical procedure for malignancies, is a typical complication or a rare event in the pediatric population. Eighty-one questionnaires were mailed to members of The Japanese Society of Pediatric Endosurgeons. They were asked to provide a list of their institutions that had experience with PSR after endosurgical procedures for pediatric malignancies. Among 29 institutions, a total of 129 endosurgical procedures for pediatric malignancies were reported; these included 85 laparoscopic and 44 thoracoscopic procedures, performed on 104 neuroblastomas, 8 hepatoblastomas, 7 nephroblastomas, and 10 other tumors. Of the 104 neuroblastomas, 83 were found by mass screening using high levels of urinary vanillylmandelic acid and homovanillic acid. Sixty-five of the 83 patients had their tumor excised, and 18 had their tumor biopsied by endosurgical procedures. Additionally, 47 of these patients did not require any postoperative chemotherapy. No incidence of PSR was reported in any of the patients that underwent endosurgical procedures. The PSR following endosurgical procedure is a rare phenomenon in the pediatric population. Both, laparoscopic and thoracoscopic procedures, are safe and recommended for treating pediatric malignancies, especially mass-screened neuroblastomas.

Reorganized small intestine from fetal mouse as an in vitro wound healing model.

BACKGROUND: We developed a method for reorganizing the mouse small intestine. In the present study, we investigated whether the reorganized small intestine was morphologically and histochemically differentiated. We also evaluated the reorganized small intestine as an in vitro wound healing model. METHODS: Fetal mouse small intestines were dispersed into single cells, which were then cultured to a high density. Newly formed small intestine-like organs on a membrane filter were observed by light and electron microscopy. Alkaline phosphatase (ALPase) activity of the epithelium was analyzed. To evaluate the reorganized small intestine as an in vitro wound healing model, a scalpel was used to cut the reorganized intestine on a membrane, and the healing process was morphologically and immunohistochemically examined. RESULTS: After 6 days in culture, the surface was almost completely coveed with epithelial cells, and villus-like structures were observed. These epithelial cells formed microvilli, and in parallel with this development, ALPase activity of the microvilli increased (from day 4). Twenty-four hours after the cutting, the wound surface was almost completely covered with undifferentiated epithelial cells. The number of acetylated low-density lipoprotein labeled with 1,1,dioctadecyll,3,3,3,3, tetramethyl-indocarbocyanine perchlorate (DiI-Ac-LDL)-positive macrophages increased after cutting. Platelet-derived growth factor (PDGF)-, basic fibroblast growth factor (bFGF)-, matrix metalloproteinase-1 (MMP-1)-positive cells were detected by immunohistochemical staining. CONCLUSIONS: The reorganized small intestine had a morphologically and histochemically differentiated organoid structure, and was useful as an in vitro model for investigating the process of wound healing.