[Basic and Advanced Techniques of Anastomosis in Deep Surgical Fields:STA-SCA Anastomosis].

This article detailly describes the subtemporal-transtentorial STA-SCA bypass technique. Through temporal base drilling, copious cerebrospinal fluid evacuation before retraction, and sufficient retraction of the temporal lobe preserving the veins of the temporal base would be primodial to obtain an appropriate surgical field. Refrection of the tentrial free edge and identification of recipient SCA posterior to the entry point of the trochlear nerve into the cavernous sinus is a micro-anatomical key. Bilateral bayonet-type needle holders and forceps should be used not to shadow the surgical corridor with one's hands.

Intake levels and main sources of nutrients for Japanese children with motor or intellectual disabilities.

Proper nutritional management is important for the growth and development of children with motor or intellectual disabilities; however, few studies have investigated the nutrient intake of children with disabilities. This study aimed to investigate the nutrient intake and food groups that are the main sources of nutrients for children with disabilities. This cross-sectional observational study included twenty-five children (mean age, 11⋅8 years) from five hospitals in Japan. Using a 3-d weighed dietary record, we estimated the daily nutrient intake and food and beverage sources that contributed to nutrient intake. The mean values of calcium, magnesium, iron, vitamin A, thiamine, riboflavin, and vitamin C intake were below the recommended dietary allowance, and those of dietary fiber and potassium were below the levels recommended by the Tentative Dietary Goal for Preventing Lifestyle-related Diseases (DG). In contrast, the mean intake values of fat, saturated fatty acids, and sodium were above the DG levels. Dairy products, meat, vegetables, and cereals were found to be the major contributors of nutrients. Increased intake of vegetables may help alleviate insufficient micronutrient intake in children with disabilities.

Proctoring System of Pediatric Laparoscopic Surgery for Choledochal Cyst.

Background: Endoscopic surgery also has been becoming widespread in the field of pediatric surgery. However, most disease treated by pediatric surgery in a single institution are small number of cases. Besides, the variety of operative procedures that need to be performed in this field is quite wide. For these reasons, pediatric surgeons have limited opportunities to perform endoscopic surgery. Therefore, it is difficult to introduce advanced endoscopic surgery at a single local hospital. To educate pediatric surgeons in local hospitals, for widespread advanced pediatric endoscopic surgery safely, and to eliminate the need for patient centralization, we have introduced a proctoring system. We compared the surgical results of our institution, a center hospital, with other local institutions, to investigate the feasibility of our proctoring system. Methods: The experienced pediatric surgeon of our institution visits local hospitals to provide onsite coaching and supervises pediatric surgeons on the learning curve. All patients who underwent laparoscopic cyst excision and hepaticojejunostomy for choledochal cysts, one of the advanced pediatric endoscopic surgeries was retrospectively reviewed. Results: Thirty-four cases were evaluated (14 cases in our institution, 20 cases in 9 other institutions). The procedures of all 34 cases were performed by surgeons with 0-2 cases of experience in the procedure. There were no open conversion cases. There was no significant difference in the operative date. There was 1 case (6.7%) of postoperative complications during hospitalization at our institution and 3 cases (14.3%) at other institutions (P = .47). Two cases of late complications (13.3%) occurred at our institution, whereas 6 cases (28.6%) occurred at other institutions (P = .28). Conclusion: With the proctoring system, the performance and completion of advanced pediatric endoscopic surgery at local institutions was feasible. This has important implications given the ever-growing demand for pediatric endoscopic surgery and the increasing need for competent pediatric endoscopic surgeons.

Molecular Identification of UDP-Sugar-Dependent Glycosyltransferase and Acyltransferase Involved in the Phenylethanoid Glycoside Biosynthesis Induced by Methyl Jasmonate in Sesamum indicum L.

Sesame (Sesamum indicum L.) plants contain large amounts of acteoside, a typical phenylethanoid glycoside (PhG) that exhibits various pharmacological activities. Although there is increasing interest in the biosynthesis of PhGs for improved production, the pathway remains to be clarified. In this study, we established sesame-cultured cells and performed transcriptome analysis of methyl jasmonate (MeJA)-treated cultured cells to identify enzyme genes responsible for glucosylation and acylation in acteoside biosynthesis. Among the genes annotated as UDP-sugar-dependent glycosyltransferase (UGT) and acyltransferase (AT), 34 genes and one gene, respectively, were upregulated by MeJA in accordance with acteoside accumulation. Based on a phylogenetic analysis, five UGT genes (SiUGT1-5) and one AT gene (SiAT1) were selected as candidate genes involved in acteoside biosynthesis. Additionally, two AT genes (SiAT2-3) were selected based on sequence identity. Enzyme assays using recombinant SiUGT proteins revealed that SiUGT1, namely, UGT85AF10, had the highest glucosyltransferase activity among the five candidates against hydroxytyrosol to produce hydroxytyrosol 1-O-glucoside. SiUGT1 also exhibited glucosyltransferase activity against tyrosol to produce salidroside (tyrosol 1-O-glucoside). SiUGT2, namely, UGT85AF11, had similar activity against hydroxytyrosol and tyrosol. Enzyme assay using the recombinant SiATs indicated that SiAT1 and SiAT2 had activity transferring the caffeoyl group to hydroxytyrosol 1-O-glucoside and salidroside (tyrosol 1-O-glucoside) but not to decaffeoyl-acteoside. The caffeoyl group was attached mainly at the 4-position of glucose of hydroxytyrosol 1-O-glucoside, followed by attachment at the 6-position and the 3-position of glucose. Based on our results, we propose an acteoside biosynthetic pathway induced by MeJA treatment in sesame.

Criteria for Preserving Grossly Ischemic Torsed Testicles Using Indocyanine Green Fluorescence Imaging: A Single-Center Case Series.

Testicular torsion (TT) is a surgical emergency requiring early diagnosis and surgical intervention to avoid testicular loss. We report 3 pediatric TT cases with testicular salvage to visualize the blood flow by indocyanine green fluorescence imaging (ICG-FI) on the tunica albuginea of the testis. ICG-FI could not confirm blood flow in the testicular parenchyma; however, it could be detected in postoperative ultrasonography. Blood visualization of the tunica albuginea by ICG-FI may have potential criteria for testicular salvage. Long-term follow-up investigations after testicular salvage are needed to conclude the ICG-FI efficacy for TT.

Traumatic pseudoaneurysm resulting from avulsion of the falcine branch of an azygos anterior cerebral artery: a case report.

Traumatic anterior cerebral artery (ACA) aneurysms are extremely rare. Traumatic anterior ACA aneurysms are thought to develop when the ACA at the pericallosal segment travel adjacent to immobile falx cerebri. As the majority of aneurysms are pseudoaneurysms, direct neck clipping is usually not possible, and it is often necessary to carry out direct or endovascular trapping in conjunction with proficient bypass techniques. The authors describe the first reported case of a traumatic ACA pseudoaneurysm resulting from avulsion of the falcine branch of an azygos ACA. In this case, the lacerated aneurysm wall was successfully sutured, without the need for a bypass. Neurosurgeons should be aware that avulsion of the falcine branch arising from the ACA can occur, and that this may cause a traumatic aneurysm on the distal ACA. Furthermore, direct suturing of a lacerated arterial wall should be considered a treatment option for this type of traumatic intracranial aneurysm.

Incidence of testicular microlithiasis after orchidopexy for cryptorchidism and its risk factors: A retrospective cohort study.

INTRODUCTION: Testicular microlithiasis (TML) is detected using scrotal ultrasound (US) and is characterized by hyperechoic non-shadowing foci 1-3 mm in diameter within the testicular parenchyma. Although a history of orchidopexy is a known risk factor for TML, and TML is a relatively common condition in postoperative cryptorchidism patients, no previous report has focused on risk factors for TML after orchidopexy. OBJECTIVE: The aims of this study were to evaluate the time-dependent incidence of TML after orchidopexy for cryptorchidism and to identify risk factors for TML. STUDY DESIGN: This study included patients who underwent primary orchidopexy for cryptorchidism between 2004 and 2018 and could be evaluated using scrotal US before and after the procedure. Patients with chromosomal abnormalities and those with preoperative TML were excluded. The Kaplan-Meier method was used to assess postoperative TML appearance. The Cox proportional hazard model was used to evaluate three potential risk factors for postoperative TML: higher testicular position (proximal to the external inguinal ring), delayed orchidopexy (after 18 months of corrected age), and bilateral cryptorchidism. RESULTS: A total of 214 testes from 163 patients were eligible for inclusion (operative age and follow-up time: 2.2 years ± 18 months and 6.3 years ± 46 months, respectively). TML was found in 14/163 patients (8.6%) and 17/214 testes (8.1%). No testicular tumors were discovered during follow-up. The time-dependent TML incidence was 6.0% at 5 years and 11.2% at 10 years after surgery (Summary figure). A higher testicular location proximal to the external inguinal ring was found to be an independent risk factor in the Cox proportional hazard model (hazard ratio 6.18, 95% confidence interval 1.37-27.9, Summary figure). DISCUSSION: Our findings show that the incidence of postoperative TML increases for approximately 10 years following orchidopexy and is associated with a higher testicular location proximal to the external inguinal ring at surgery. In the adult population, TML with a history of cryptorchidism is a known risk factor of testicular malignancy. Given that more than 20% of boys with a higher testicular position developed TML, US evaluation to detect TML during pubety is feasible for the patients with a history of orchidopexy. CONCLUSION: The incidence of postoperative TML in boys with cryptorchidism rises until puberty and is strongly associated with a higher testicular position at orchidopexy.

[Changes in Test Methods for Internationalization in the Japanese Pharmacopoeia (Part 2): Establishment of a Quantitative Method for Lorazepam Using HPLC Analysis].

The Japanese Pharmacopoeia (JP) is an official normative publication that is referred to, for establishing the authenticity and properties and maintaining the quality of pharmaceutics in Japan. Partial amendments are periodically made to these guidelines to keep up with the progress of science and technology, and the international harmonization is revised every 5 years. Thus, "Internationalization of the JP" is one of the more important issues to address for the revision of the JP. For example, the incorporation of the test methods that have been used in other pharmacopeias, such as the United States Pharmacopeia (USP) and the European Pharmacopoeia (EP), into the JP is a useful approach. In light of this, we have recently reported changes in test methods in the 17th JP, "Establishment of a quantitative test method for clonidine hydrochloride from using a potentiometric titration method to using HPLC". As a part of our ongoing research to change test methods for internationalization, we selected lorazepam. Lorazepam is analyzed using a potentiometric titration method as listed in the 17th JP; however, both the USP and EP use HPLC for quantitative analysis of this drug. In this study, we synthesized the related impurities of lorazepam listed in the USP and the EP and determined their purities using quantitative NMR. The separation conditions of these compounds, including lorazepam, were examined using HPLC and simultaneous analyses were performed. In addition, lorazepam extracted from the tablets was analyzed using conditions similar to those used for the analysis of the related impurities.

Development of Agonist-Based PROTACs Targeting Liver X Receptor.

Liver X receptors (LXRs) belong to the nuclear hormone receptor superfamily and function as ligand-dependent transcription factors that regulate cholesterol homeostasis, lipid homeostasis, and immune responses. LXR antagonists are promising treatments for hypercholesterolemia and diabetes. However, effective LXR antagonists and inhibitors are yet to be developed. Thus, we aimed to develop LXR degraders (proteolysis targeting chimeras PROTACs against LXR) as a complementary strategy to provide a similar effect to LXR inhibition. In this study, we report the development of GW3965-PEG5-VH032 (3), a PROTAC capable of effectively degrading LXRß protein. Compound 3 induced the ubiquitin-proteasome system-dependent degradation of the LXRß protein, which requires VHL E3 ligase. We hope that PROTACs targeting LXR proteins will become novel therapeutic agents for LXR-related diseases.

[Changes in Test Methods for Internationalization in the Japanese Pharmacopoeia (Part 1): Establishment of a Quantitative Test Method for Clonidine Hydrochloride Using HPLC Analysis].

The Japanese Pharmacopoeia (JP) is an official normative guide for maintaining the authenticity of properties and qualities of medicine in Japan. The JP is revised every 5 years, and partial amendments are made from time to time to keep abreast with progress in science and technology and international harmonization. We are conducting a related study on the elimination of toxic reagents from the JP. The elimination of toxic reagents is an important study in relation to the five pillars of the revision of the 18th JP, "Improvement in quality by proactively introducing the latest knowledge and technological advances". In addition, "Internationalization of the JP" is an important issue to be addressed during revision of the JP. Considering international harmonization of the JP, it is important to incorporate the test methods that have been used in other pharmacopoeia, such as the United States Pharmacopeia (USP) and the European Pharmacopoeia (EP) in the JP. To achieve the above, herein, we selected clonidine hydrochloride, which is listed in the 17th JP. A potentiometric titration method is used as a quantitative method for clonidine hydrochloride in the 17th JP; in contrast, a HPLC method is utilized in the USP and the EP. In this study, we synthesized impurities of clonidine hydrochloride and determined their purities using quantitative NMR. In addition, the complete separation conditions of these compounds by HPLC were examined, and simultaneous analysis was performed.

Determination of Mogroside V in Luohanguo Extract for Daily Quality Control Operation Using Relative Molar Sensitivity to Single-Reference Caffeine.

Mogroside V is one of the characteristic and effective components of luohanguo extract, a food additive used as a sweetener in Japan as per Japan's Standards and Specifications for Food Additives (JSFA; 9th ed.). JSFA stipulates that the quantitative determination for mogroside V content in luohanguo extract applies HPLC using analytical standard mogroside V. However, no mogroside V reagents with proven purities are commercially available. Therefore the current JSFA determination method is not particularly suited for daily quality control operations involving luohanguo extract. In this study, we applied an alternative quantitative method using a single reference with relative molar sensitivity (RMS). It was possible to calculate the accurate RMS by an offline combination of 1H-quantitative NMR spectroscopy (1H-qNMR) and an HPLC/variable-wavelength detector (VWD). Using the RMS of mogroside V to a commercial certified reference material grade caffeine, the mogroside V contents in luohanguo extracts could be determined using HPLC/VWD without analytical standard mogroside V. There was no significant difference between the mogroside V contents in luohanguo extracts determined using the method employing single-reference caffeine with the RMS and using the JSFA method. The absolute calibration curve for the latter was prepared using an analytical standard mogroside V whose purity was determined by 1H-qNMR. These results demonstrate that our proposed method using a single reference with RMS is suitable for quantitative determination of mogroside V in luohanguo extract and can be used as an alternative method to the current assay method in JSFA.

Development of an HPLC method with relative molar sensitivity based on 1H-qNMR to determine acteoside and pedaliin in dried sesame leaf powders and processed foods.

A high-performance liquid chromatography (HPLC) method with relative molar sensitivity (RMS) based on 1H quantitative NMR spectroscopy (1H-qNMR) has been developed for food ingredients such as acteoside (verbascoside) and pedaliin (pedalitin-6-O-glucoside) without requiring authentic and identical standards as the reliable analytical methods. This method is used methyl 4-hydroxybenzoate (MHB) as an alternative reference standard. Each RMS is also calculated from the ratio of each analyte's molar absorption coefficient to that of MHB after correcting the purities of the analytes and reference standard by 1H-qNMR. Therefore, this method can quantify several analytes with metrological traceability to the International System of Units (SI) using the RMS and one alternative reference standard. In this study, the content of acteoside and pedaliin in several samples, such as dried sesame leaf powders and commercially processed foods, can be determined by the proposed RMS method and demonstrated in good agreement that obtained by a conventional method. Moreover, the proposed method yields analytical data with SI-traceability without the need for an authentic and identical analyte standard. Thus, the proposed RMS method is a useful and practical tool for determining acteoside and pedaliin in terms of the accuracy of quantitative values, the routine analysis, and the cost of reagents.

The clinical outcomes of pediatric inguinal hernia repairs operated by surgical residents.

BACKGROUND: Inguinal hernia is one of the most common surgical diseases, and surgical residents perform inguinal hernia repairs during pediatric surgery rotation. The aims of this study were to examine the clinical outcomes of pediatric inguinal herniorrhaphy performed by surgical residents and to assess the suitability for surgical training. METHODS: We extracted data on elective unilateral inguinal hernia repairs performed in children between 2014 and 2018. All eligible cases were divided into surgical resident and attending surgeon groups according to the operator. We reviewed medical records retrospectively and compared some clinical indicators between the 2 groups. RESULTS: Of 294 eligible cases, 163 were performed by 37 surgical residents and 131 were performed by 4 attending surgeons. The median operative times in the resident and attending surgeon groups were 30 and 19 min, respectively. Operative time was statistically longer in the resident group (p < 0.001). The complication and recurrence rates in the resident and attending surgeon groups were 11.0% and 11.5%, and 0% and 0.8%, respectively (p = 1.000 and p = 0.466). CONCLUSION: Inguinal hernia repairs could be properly performed by surgical trainees with the assistance of attending surgeons. Hernia operation might provide good opportunities for surgical residents to practice basic surgical skills.

Acquired isolated hypoganglionosis as a distinct entity: results from a nationwide survey.

PURPOSE: Acquired isolated hypoganglionosis (A-IH) is a late-onset intestinal pseudo-obstruction disorder and shows different pathophysiological findings from congenital isolated hypoganglionosis (C-IH). In this study, we retrospectively examined five cases of A-IH and investigated the features of A-IH. METHODS: Five cases of A-IH were extracted from a nationwide retrospective cohort study in 10 years, from which totally 355 cases of Allied Disorders of Hirschsprung's Disease (ADHD) were collected. RESULTS: Ages of onset were between 13 and 17 years in three cases, and 4 years and 4 months in ones. Initial symptoms were abdominal distension and/or chronic constipation in 4 cases, whereas one exhibited intestinal perforation. Affected lesions varied from case to case, extending various length of intestinal tracts. All cases underwent multiple operations (average: 4.6 times), such as enterostomy, resection of dilated intestines, and/or pull-through. Pathological findings showed the decreased numbers of ganglion cells and degeneration of ganglion cells, whereas the size of the plexus was normal. Currently, all cases were alive and almost all eat regular food without requiring parenteral feeding. CONCLUSION: A-IH is rare, but distinct entity characterized by different clinical courses and pathological findings from those of C-IH. The outcome is considered to be favorable after a resection of affected intestine.

Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease, 2017.

BACKGROUND: Despite the presence of ganglion cells in the rectum, some patients have symptoms similar to those of Hirschsprung's disease. A consensus has yet to be established regarding the terminology for these diseases. We defined this group of diseases as "allied disorders of Hirschsprung's disease" and compiled these guidelines to facilitate accurate clinician diagnosis and provide appropriate treatment strategies for each disease. METHODS: These guidelines were developed using the methodologies in the Medical Information Network Distribution System (MINDS). Of seven allied disorders, isolated hypoganglionosis; megacystis-microcolon-intestinal hypoperistalsis syndrome; and chronic idiopathic intestinal pseudo-obstruction were selected as targets of clinical questions (CQ). In a comprehensive search of the Japanese- and English-language articles in PubMed and Ichu-Shi Web, 836 pieces of evidence related to the CQ were extracted from 288 articles; these pieces of evidence were summarized in an evidence table. RESULTS: We herein outline the newly established Japanese clinical practice guidelines for allied disorders of Hirschsprung's disease. Given that the target diseases are rare and intractable, most evidence was drawn from case reports and case series. In the CQ, the diagnosis, medication, nutritional support, surgical therapy, and prognosis for each disease are given. We emphasize the importance of full-thickness intestinal biopsy specimens for the histopathological evaluation of enteric ganglia. Considering the practicality of the guidelines, the recommendations for each CQ were created with protracted discussions among specialists. CONCLUSIONS: Clinical practice recommendations for allied disorders of Hirschprung's disease are given for each CQ, along with an assessment of the current evidence. We hope that the information will be helpful in daily practice and future studies.

Chemical characterization and biological activity in young sesame leaves (Sesamum indicum L.) and changes in iridoid and polyphenol content at different growth stages.

Three iridoids (lamalbid (I1), sesamoside (I2) and shanzhiside methyl ester (I3)) and seven polyphenols (cistanoside F (P1), chlorogenic acid (P2), pedalitin-6-O-laminaribioside (P3), pedaliin (P4), isoacteoside (P6), pedalitin (P7) and martynoside (P8)) were identified in young sesame leaves (Sesamum indicum L.) other than the acteoside (P5) reported previously. P3 was a new compound, and I1, I3, P2 and P8 were found in a species of Sesamum for the first time. HPLC analyses revealed that the compounds I1 (0.29-1.75% of dry leaves), I2 (0.38-0.87%), I3 (0.04-1.07%), P4 (0.01-2.05%) and P5 (0.13-4.86%) were present primarily in young sesame leaves and were found in plants cultivated on different farms (plant height, 30-70 cm). Of the identified compounds, P5 and P6 showed high 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical scavenging, oxygen radical absorbance capacity (ORAC), and in vitro antiglycation activities. Given its content, P5 makes a major contribution to the biological activities of young sesame leaves. The compounds were examined at six different growth stages of plants cultured in a greenhouse to determine the optimum harvest stage and for end-use assessment. P5 accumulated in the leaves during growth, and the content reached a maximum of 12.9% of dry leaves in the 4th stage (plant height, 74.5±9.7 cm), which is one of the highest percentages reported in plants from nature.