Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Gastrectomy reduces pancreatic secretory function via pancreatic atrophy

PURPOSE

Although reports suggest that the pancreatic volume decreases after gastrectomy for gastric cancer, the relationship between the pancreatic volume and secretory function after gastrectomy remains unclear. In this study, we examined the relationship between the pancreatic volume and exocrine and endocrine functions after total gastrectomy.

METHODS

The pancreatic volumes of 18 distal gastrectomy and 15 total gastrectomy patients were retrospectively measured using computed tomography volumetry up to 5 years postoperatively. Ten low anterior resection patients were selected as controls. In addition, the pancreatic volume and exocrine function evaluated by fecal elastase and the insulin secretory function evaluated by glucagon tolerance testing were prospectively examined before and one year after surgery in nine cases of total gastrectomy.

RESULTS

After low anterior resection, the pancreatic volume did not change, but after distal and total gastrectomy, the pancreatic volume decreased continuously until the fifth year. After total gastrectomy, fecal elastase decreased significantly from 865.8 μg/g to 603.2 μg/g in the first year (p = 0.0316), and the insulin secretion capacity also decreased significantly from 3.83 ng/mL to 2.26 ng/mL (p = 0.0019).

CONCLUSIONS

The pancreatic volume decreases continuously after gastrectomy for gastric cancer, and the pancreatic exocrine and endocrine functions decrease along with pancreatic atrophy after total gastrectomy.

Drug-induced interstitial lung disease after chemoimmunotherapy for extensive-stage small cell lung cancer

Objectives

The combination of chemotherapy and immune checkpoint inhibitors (chemo-ICI) has become the new standard of treatment for extensive-stage small cell lung cancer (ES-SCLC). Recently, slight changes in interstitial shadows, defined as interstitial lung abnormalities (ILA), have been identified. In patients with ES-SCLC who received chemo-ICI, there are limited data on the incidence of drug-induced interstitial lung disease (D-ILD) in daily practice and the association between the development of D-ILD and ILA in the baseline computed tomography (CT).

Materials and methods

A multicenter, retrospective study was conducted to investigate the incidence of D-ILD, the risk factors for developing D-ILD, progression-free survival (PFS), and overall survival (OS) in patients with ES-SCLC who received chemo-ICI between August 2019 and November 2021.

Results

This study enrolled 70 patients (median age, 71 years; including 58 men) from nine institutions in Japan. There were 62 patients (89%) treated with carboplatin/etoposide/atezolizumab and 8 patients treated with carboplatin or cisplatin/etoposide/durvalumab. Twenty-nine patients (41.4%) were found to have ILA at baseline CT. Eleven patients (15.7%) developed D-ILD. The proportion of patients with ILA was significantly higher in the group who developed D-ILD than in the group who did not (9/11 (81.8%) vs. 20/59 (33.9%), respectively, P = 0.0057). In addition, the frequency of ground glass attenuation (GGA) and reticulation was higher in patients who developed D-ILD. There was no significant difference in PFS and OS between patients who developed D-ILD and those who did not (median PFS, 8.0 (95% confidence interval (CI), 5.5-9.5) months vs. 5.0 (95% CI, 4.5-5.6) months, respectively, P = 0.11 and median OS, not reached (NR) (95% CI, 8.7-NR) vs. 18.2 (95% CI, 13.2-NR) months, respectively, P = 0.20).

Conclusion

The incidence of D-ILD in patients with ES-SCLC who received chemo-ICI in clinical practice was higher than that in clinical trials. Patients with pre-existing ILA were more likely to develop D-ILD.

Inhibition of Mertk Signaling Enhances Bone Healing after Tooth Extraction

Regeneration of alveolar bone is an essential step in restoring healthy function following tooth extraction. Growth of new bone in the healing extraction socket can be variable and often unpredictable when systemic comorbidities are present, leading to the need for additional therapeutic targets to accelerate the regenerative process. One such target is the TAM family (Tyro3, Axl, Mertk) of receptor tyrosine kinases. These proteins have been shown to help resolve inflammation and maintain bone homeostasis and thus may have therapeutic benefits in bone regeneration following extraction. Treatment of mice with a pan-TAM inhibitor (RXDX-106) led to accelerated alveolar bone fill following first molar extraction in a mouse model without changing immune infiltrate. Treatment of human alveolar bone mesenchymal stem cells with RXDX-106 upregulated Wnt signaling and primed the cells for osteogenic differentiation. Differentiation of human alveolar bone mesenchymal stem cells with osteogenic media and TAM-targeted inhibitor RXDX-106 (pan-TAM), ASP-2215 (Axl specific), or MRX-2843 (Mertk specific) showed enhanced mineralization with pan-TAM or Mertk-specific inhibitors and no change with Axl-specific inhibitor. First molar extractions in Mertk-/- mice had increased alveolar bone regeneration in the extraction socket relative to wild type controls 7 d postextraction. Flow cytometry of 7-d extraction sockets showed no difference in immune cell numbers between Mertk-/- and wild type mice. RNAseq of day 7 extraction sockets showed increased innate immune-related pathways and genes associated with bone differentiation in Mertk-/- mice. Together, these results indicate that TAM receptor signaling, specifically through Mertk, can be targeted to enhance bone regeneration after injury.

Short- and long-term outcomes of laparoscopic versus open repeat liver resection for hepatocellular carcinoma: A multicenter study

OBJECTIVE

This multicenter study aimed to compare the short- and long-term outcomes of laparoscopic (LRLR) versus open repeat liver resection (ORLR) for recurrent hepatocellular carcinoma (HCC) using propensity score matching (PSM). Despite the expanding indications for laparoscopic liver resection, limited data regarding the outcomes of LRLR have previously been reported.

METHODS

This study included patients who underwent repeat liver resection for recurrent HCC. Patients were divided into the LRLR and ORLR groups, and their short- and long-term outcomes were compared via PSM.

RESULTS

There were 256 and 130 patients in the ORLR and LRLR groups, respectively. After PSM, 64 patients were included in each group. Intraoperative blood loss was significantly less in LRLR than in ORLR (56 vs 208 ml, P < .001). Postoperative complications of Clavien-Dindo IIIa or more were significantly less in LRLR than in ORLR (3.1% vs 15.6%, P = .030). The length of hospital stay was notably shorter in LRLR than in ORLR (9 vs 12 days, P < .001). Survival rates after repeat liver resection at 1, 3, and 5 years, respectively, were comparable at 93.4%, 81.9%, and 63.5% for ORLR and at 94.8%, 80.7%, and 67.3% for LRLR (P = .623). Subgroup analysis of patients who underwent wedge resection in repeat liver resection revealed that the postoperative complication rate was notably lower in LRLR than in ORLR (7.2% vs 21.8%, P = .030).

CONCLUSION

LRLR for recurrent HCC is a viable option due to its better short-term outcomes and comparable long-term outcomes compared to ORLR.

Drug-induced interstitial lung disease due to over-the-counter cold medicine taken daily for 25 years: a case report

INTRODUCTION

We report a rare case of drug-induced interstitial lung disease due to over-the-counter cold medicine taken daily for 25 years to clear the patient's head.

CASE PRESENTATION

A 77-year-old Japanese man presented to our hospital with a worsening cough that started 5 years ago. Chest radiographs and computed tomography images showed bilateral opacities, and transbronchial lung biopsy specimens showed an organizing pneumonia pattern. He reported taking the same over-the-counter cold medicine daily for the past 25 years to clear his head. We suspected that the cold medicine caused the lung opacities and asked him to stop taking them. His cough, general fatigue, and chest infiltrate gradually diminished. However, 6 months later, he resumed the same treatment because of a cold. The following month, he presented with severe worsening cough and chest radiographical findings. We diagnosed drug-induced interstitial lung disease. He improved by stopping the cold medicine again and taking prednisolone.

CONCLUSIONS

Over-the-counter cold medicines are easily accessible at the drugstore. In cases of diffuse lung disease, we should consider drug-induced interstitial lung disease due to over-the-counter cold medicine, which patients have been taking not only for weeks or months but also years.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Surgical Outcomes for Hepatocellular Carcinoma in Patients with Child-Pugh Class B: a Retrospective Multicenter Study

BACKGROUNDS

Liver resection for hepatocellular carcinoma (HCC) in patients with Child-Pugh class (CPC) B increases the incidence of postoperative complication and in-hospital death and decreases the disease-free survival (DFS) and overall survival (OS) compared with those with CPC A. Conversely, some selected patients possibly gained benefits for liver resection.

METHODS

Clinical records of 114 patients with CPC B who underwent liver resection for HCC were retrospectively reviewed. The risk of postoperative complications (Clavien-Dindo classification grade of ≥ II), postoperative recurrence, and death was analyzed.

RESULTS

Postoperative complications occurred in 36 patients (31.6%), and 2 died within 90 days postoperatively due to the liver and respiratory failure, respectively. Multivariate analysis indicated that albumin-bilirubin (ALB) grade III and extended operation time were found as independent risk factors for postoperative complications. The DFS and OS rates at 3/5 years after liver resection were 30.8%/25.3% and 68.4%/48.9%, respectively. Multivariate analysis indicated that the extended blood loss, high α-fetoprotein (AFP) level (≥ 200 ng/mL), and Barcelona Clinic Liver Cancer stage C were found to be independent risk factors for postoperative recurrence. The high AFP level was also an independent prognostic factor for OS. Patients with high AFP levels had postoperative recurrence within 2 years and a higher number of extrahepatic recurrences than those with low AFP levels (< 200 ng/mL).

CONCLUSION

For patients with HCC with CPC B who were scheduled for liver resection, ALBI grade III and high AFP level should be considered as unfavorable outcomes after liver resection.

The Prognostic Value of Preoperative Serum Markers and Risk Classification in Patients with Hepatocellular Carcinoma

BACKGROUND

Complex hepatocellular carcinoma (HCC) prognostic biomarkers have been reported in various studies. We aimed to establish biomarkers that could predict prognosis, and formulate a simple classification using non-invasive preoperative blood test data.

METHODS

We retrospectively identified 305 patients for a discovery cohort who had undergone HCC-related hepatectomy at four Japanese university hospitals between January 1, 2011 and December 31, 2013. Preoperative blood test parameter optimal cut-off values were determined using receiver operating characteristic curve analysis. Cox uni- and multivariate analyses were used to determine independent prognostic factors. Risk classifications were established using classification and regression tree (CART) analysis. Validation was performed with 267 patients from three other hospitals.

RESULTS

In multivariate analysis, α-fetoprotein (AFP, p < 0.001), protein induced by vitamin K absence or antagonist-II (PIVKA-II, p = 0.006), and C-reactive protein (CRP, p < 0.001) were independent prognostic factors for overall survival (OS). AFP (p = 0.007), total bilirubin (p = 0.001), and CRP (p = 0.003) were independent recurrent risk factors for recurrence-free survival (RFS). CART analysis results formed OS (CRP, AFP, and albumin) and RFS (PIVKA-II, CRP, and total bilirubin) decision trees, based on machine learning using preoperative serum markers, with three risk classifications. Five-year OS (low risk, 80.0%; moderate risk, 56.3%; high risk, 25.2%; p < 0.001) and RFS (low risk, 43.4%; moderate risk, 30.8%; high risk, 16.6%; p < 0.001) risks differed significantly. These classifications also stratified OS and RFS risk in the validation cohort.

CONCLUSION

Three simple risk classifications using preoperative non-invasive prognostic factors could predict prognosis.

Early vascular responses to abluminal biodegradable polymer-coated versus circumferential durable polymer-coated newer-generation drug-eluting stents in humans: a pathologic study

Background

Recent clinical trials are testing strategies for short (1–3 months) dual antiplatelet therapy (DAPT) following newer-generation drug-eluting stent (DES) placement. However, the safety of short DAPT regimens is not supported by biological evidence in humans.

Purpose

We sought to evaluate early pathologic responses to newer-generation DES by comparing abluminal biodegradable polymer-coated DES (BP-DES) with circumferential durable polymer-coated DES (DP-DES) in human autopsy cases.

Methods

The study included a total of 37 coronary lesions with thin strut newer-generation DES (DP-DES=23 [XIENCE=18, Resolute Integrity=5] and BP-DES=14 [SYNERGY=9, Ultimaster=5]) with duration of implantation &lt;90 days in 25 autopsy cases. The process of stent healing was precisely evaluated for every single strut in association with underlying tissue characteristics. The degree of strut coverage was defined as follows: grade 0 (bare struts), grade 1 (struts covered with thrombus, fibrin, or other tissues or cells without endothelium), grade 2 (struts covered with single-layered endothelium without underlying smooth muscle cell layers), and grade 3 (struts covered with endothelium and underlying smooth muscle cell layers) (Figure 1).

Results

Duration of implantation was similar in lesions with DP-DES and those with BP-DES (median=20 vs. 17 days). A total of 1986 struts (DP-DES=1261, BP-DES=725) were pathologically analyzed. Focal grade 2 coverage was observed as early as 5 days after the implantation in both stents. Multilevel mixed-effects ordered logistic regression model demonstrated that BP-DES exhibited greater strut coverage compared with DP-DES (odds ratio; 3.50, 95% CI; 1.31–9.41, P=0.013), which remained significant after adjustment for duration of implantation and underlying tissue characteristics (odds ratio; 2.64, 95% CI; 1.04–6.68, P=0.040). The time course of vessel healing assessed as predictive probability of strut coverage (grade 0–3) stratified by duration of implantation is shown in Figure 2. Predictive probability of grade 2 and 3 coverage was comparably limited at 30 days (DP-DES=17.7% vs. BP-DES=29.0%) and increased at 90 days (DP-DES=76.1% vs. BP-DES=85.9%). Both stents showed few inflammation and similar degree of fibrin deposition.

Conclusions

The current first pathologic study on early biological responses to newer-generation DES in humans demonstrated that single-layered endothelial coverage begins in days following the stent placement, and abluminal BP-DES potentially exhibit faster strut coverage with smooth muscle cell infiltration than circumferential DP-DES. Nevertheless, vessel healing remains suboptimal at 30 days in both DP- and BP-DES, which progresses with time to become substantial at 90 days. Our results suggest that very short duration of DAPT for 1 month should be applied with caution, taking into account the trade-off between bleeding and thrombotic risks.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research (C) from the Japan Society for the Promotion of Science

Increased levels of a pro-inflammatory IgG receptor in the midbrain of people with schizophrenia

BACKGROUND

There is growing evidence that neuroinflammation may contribute to schizophrenia neuropathology. Elevated pro-inflammatory cytokines are evident in the midbrain from schizophrenia subjects, findings that are driven by a subgroup of patients, characterised as a "high inflammation" biotype. Cytokines trigger the release of antibodies, of which immunoglobulin G (IgG) is the most common. The level and function of IgG is regulated by its transporter (FcGRT) and by pro-inflammatory IgG receptors (including FcGR3A) in balance with the anti-inflammatory IgG receptor FcGR2B. Testing whether abnormalities in IgG activity contribute to the neuroinflammatory abnormalities schizophrenia patients, particularly those with elevated cytokines, may help identify novel treatment targets.

METHODS

Post-mortem midbrain tissue from healthy controls and schizophrenia cases (n = 58 total) was used to determine the localisation and abundance of IgG and IgG transporters and receptors in the midbrain of healthy controls and schizophrenia patients. Protein levels of IgG and FcGRT were quantified using western blot, and gene transcript levels of FcGRT, FcGR3A and FcGR2B were assessed using qPCR. The distribution of IgG in the midbrain was assessed using immunohistochemistry and immunofluorescence. Results were compared between diagnostic (schizophrenia vs control) and inflammatory (high vs low inflammation) groups.

RESULTS

We found that IgG and FcGRT protein abundance (relative to β-actin) was unchanged in people with schizophrenia compared with controls irrespective of inflammatory subtype. In contrast, FcGRT and FcGR3A mRNA levels were elevated in the midbrain from "high inflammation" schizophrenia cases (FcGRT; p = 0.02, FcGR3A; p < 0.0001) in comparison to low-inflammation patients and healthy controls, while FcGR2B mRNA levels were unchanged. IgG immunoreactivity was evident in the midbrain, and approximately 24% of all individuals (control subjects and schizophrenia cases) showed diffusion of IgG from blood vessels into the brain. However, the intensity and distribution of IgG was comparable across schizophrenia cases and control subjects.

CONCLUSION

These findings suggest that an increase in the pro-inflammatory Fcγ receptor FcGR3A, rather than an overall increase in IgG levels, contribute to midbrain neuroinflammation in schizophrenia patients. However, more precise information about IgG-Fcγ receptor interactions is needed to determine their potential role in schizophrenia neuropathology.

Risk factors for and management of morbidity in pure laparoscopic resection of the right posterosuperior segments of the liver: A multicenter retrospective study

BACKGROUND

This study aimed to determine the risk factors for severe postoperative complications in patients undergoing pure laparoscopic liver resection (LLR) for tumors in the right posterosuperior (PS) segments.

METHODS

The study included 289 patients who underwent parenchyma-sparing pure LLR for tumors in the right PS segments at eight treatment centers between January 2009 and December 2019.

RESULTS

Multivariate analysis revealed tumor size ≥3 cm (P = .016), segmentectomy (P = .044), and liver cirrhosis (P = .029) as independent risk factors for severe postoperative complications. The severe complication rates (2.7% vs 12.1%, P = .0025), median intraoperative blood loss (100 mL vs 150 mL, P = .001), and median operation time (248 minutes vs 299.5 minutes, P = .0013) were lower in the patients without all these three risk factors than those with at least one risk factor. The median length of postoperative hospital stay was shorter in patients with no risk factors than those with at least one risk factor (9 days vs. 10 days, P = .001).

CONCLUSIONS

Tumor size ≥3 cm, segmentectomy, and liver cirrhosis were the risk factors for severe postoperative complications after parenchyma-sparing pure LLR for tumors in the right PS segments. Patients without these three risk factors would be appropriate candidates for safely performing parenchyma-sparing pure LLR in the right PS segments at the outset.

Longitudinal Pancreaticojejunostomy for Pancreaticodigestive Tract Anastomotic Stricture After Pancreaticoduodenectomy

Aim

Pancreaticodigestive tract anastomotic stricture is a long-term complication of pancreticoduodenectomy (PD). However, optimal treatment has not yet been defined. We conducted longitudinal pancreaticojejunostomy (LPJ) in symptomatic patients with anastomotic stricture after PD. This study aimed to evaluate the efficacy of this procedure.

Methods

Pancreticoduodenectomy was performed in 605 patients at our institution between January 2005 and April 2020. Of these, 15 patients (2.5%) developed symptomatic pancreaticodigestive tract anastomotic stricture after PD. Three patients were referred to our institution owing to recurrent pancreatitis with anastomotic stricture after PD. LPJ was indicated for these 18 patients, and they were enrolled in this study.

Results

The median time from the initial operation to LPJ was 2.0 y. Preoperative clinical presentations included obstructive pancreatitis in 10 patients, a rapid deterioration of glucose tolerance in nine, and severe steatorrhea in two. Surgical morbidity ≥grade III defined by the Clavien-Dindo classification was not observed. After LPJ, preoperative symptoms improved in 16 patients (89%) during a median follow-up of 39 mo. Nine of the 10 patients with obstructive pancreatitis achieved complete pain relief. All nine patients with a rapid deterioration of glucose tolerance showed improved endocrine function. Daily insulin requirement was significantly decreased after LPJ (11.6 ± 3.3 vs 3.4 ± 4.3 units, P = .0239). Four of the seven patients who required insulin injections were free of insulin after LPJ.

Conclusion

LPJ is a safe and effective surgical procedure for symptomatic patients with stricture of the pancreaticodigestive tract anastomosis after PD.

Efficacy of the slow firing method using a reinforced triple-row stapler for preventing postoperative pancreatic fistula during laparoscopic distal pancreatectomy

PURPOSE

Postoperative pancreatic fistula (POPF) remains the most clinically relevant complication of laparoscopic distal pancreatectomy (LDP). The present study evaluated the efficacy of the "slow firing method" using a reinforced triple-row stapler (Covidien, Tokyo, Japan) during LDP.

METHODS

This retrospective single-center study included 73 consecutive patients who underwent LDP using the slow firing method. A black cartridge was used in all patients. The primary endpoint was the rate of clinically relevant POPF (CR-POPF) after LDP. Secondary endpoints included perioperative outcomes and factors associated with CR-POPF as well as the correlation between the transection time and thickness of the pancreas.

RESULTS

Four patients (5.5%) developed CR-POPF (grade B). Overall morbidity rates, defined as grade ≥ II and ≥ III according to the Clavien-Dindo classification, were 21 and 11%, respectively. The median postoperative hospital stay was 10 days. Preoperative diabetes (13.6 vs. 0.2%, P = 0.044) and thickness of the pancreas ≥ 15 mm (13.8% vs. 0%, P = 0.006) were identified as independent risk factors for CR-POPF. The median transection time was 16 (8-29) min.

CONCLUSION

The slow firing method using a reinforced triple-row stapler for pancreatic transection is simple, safe, and effective for preventing CR-POPF after LDP.

Lung adenocarcinoma concomitant with xeroderma pigmentosum: a case report

BACKGROUND

Xeroderma pigmentosum is a rare, autosomal-recessive photosensitive dermatosis. Patients with xeroderma pigmentosum have an impaired ability to repair deoxyribonucleic acid damage caused by ultraviolet rays, resulting in skin cancer. Patients with xeroderma pigmentosum are more susceptible to some cancers. We herein report a case of xeroderma pigmentosum accompanied by lung cancer.

CASE PRESENTATION

The patient was a Japanese woman in her 70s with a family history of consanguineous marriage. Her medical history included squamous cell carcinoma and basal cell carcinoma, in addition to xeroderma pigmentosum. She presented with dry skin with small, pigmented spots, which were particularly focused around the areas exposed to sunlight. Chest computed tomography was conducted to assess for any evidence of metastatic skin carcinoma, and revealed a tumor in the left upper subpleural lobe of the lung. Consequently, she was referred to our department. Finally, we diagnosed lung adenocarcinoma (pT2aN0M1b: stage IVA). She had an epidermal growth factor receptor (EGFR) mutation (p.L858R). Treatment with an epidermal growth factor receptor tyrosine kinase inhibitor (gefitinib) was initiated, and the tumor gradually regressed. No side effects were observed. However, she later died from aspiration pneumonia.

CONCLUSIONS

Although xeroderma pigmentosum is rare, a history of consanguineous marriage should be verified. Because of the severe side effects of cisplatin and radiotherapy in xeroderma pigmentosum patients, the risks and benefits of treatment should be considered thoroughly.

New methods for determination of the keyhole position in the lateral suboccipital approach to avoid transverse-sigmoid sinus injury: Proposition of the groove line as a new surgical landmark

PURPOSE

The asterion is frequently used as an anatomical landmark to determine the location of a keyhole in the lateral suboccipital approach used in craniotomies. However, the asterion may not be ideal because of large individual differences among patients. We examined a simple and safe method for determining an optimal keyhole position (KP) using the digastric groove as a new landmark in the lateral suboccipital approach.

METHODS

Thirty-three patients with trigeminal neuralgia who underwent surgery in our institute between April 2014 and December 2018 were included. The groove line (GL) was designed accurately, extending the digastric groove on the surface of the occipital bone, as the x-axis. The y-axis was depicted from the posterior edge of the digastric groove (the groove point: GP) vertical to the GL. The x-y coordinates represented the distances from GP on each axis. The x-y coordinates of median edge of the transverse-sigmoid sinus (TSJ point), asterion, and the intersection of the GL and transverse sinus (the transverse point: TP) were investigated, based on intraoperative findings and recorded videos.

RESULTS

The x-y coordinated of the TSJ point were (23.9±3.9, 7.2±3.6). In all patients, the TSJ point was located superior to the GL. The x-y coordinates of the asterion were (27.3±6.0, 8.9±4.1), and in 28 of the 33 patients, their coordinates exceeded the TSJ points. The x-coordinate of the TP was 29.5±4.5, and was located behind the TSJ point on the GL in all patients. The shortest distance between the TSJ points and TP was approximately 3mm. According to these measurements, we decided that the optimal KP would be at 20mm from the GP, subjacent to the GL.

CONCLUSIONS

Our methods of using the GL as a new surgical landmark for setting the optimal KP is simple, safe, and useful.

Effects of Imprinting and Water Activity on Transesterification and Thermostability with Lipases in Ionic Liquid

The effect of bio-imprinting and water activity on catalytic activities and the thermostability of lipases was investigated for transesterification using vinyl acetate and benzyl alcohol as substrates in ionic liquid, [Cnmim][PF6] (n=4,6,8), and benzene. The catalytic activities were enhanced by imprinting in benzene and [C4mim][PF6], and the relations between the transesterification activities and the water activity in both solvents were approximately bell shaped. The reactivity of the transesterification in benzene was higher than that in [C4<br /> mim][PF6]. The effects of water activity and imprinting on the kinetic parameters in [C4mim][PF6] were examined. Without controlling the water content, the values of Km,VA and Km,BA (Michaelis constants of vinyl acetate and benzyl alcohol, respectively) decreased, and the values of Vm (maximum rate) increased by imprinting. On the other hand, by controlling the water content in the organic media, the values of Vm, Km,VA, and Km,BA increased by imprinting. The activities of lipase in ionic liquid are more strongly affected by water activity and imprinting than those in benzene. We observed effects of water activity on thermostability but none from imprinting.

Statins bring the prognostic impact only in peripheral artery disease patients with elevated c-reactive proteins -subanalysis from multicenter registry-

Introduction

Recent trials demonstrated favorable effects of statins on the clinical prognosis, partly through anti-inflammatory properties, in patients with coronary artery disease. However, this favorable effect has not been fully verified in patients with peripheral arterial disease (PAD). We hypothesized that statins exert different prognostic effects depending on the degrees of inflammation at the time of endovascular therapy (EVT).

Methods

This study is a subanalysis from the Toma-Code Registry that is a Japanese prospective cohort of 2,321 consecutive patients with PAD treated by endovascular therapy in hospitals from 2014 to 2016. After the exclusion of patients without information of C-reactive protein (CRP) at the time of index EVT, 2,039 patients including 1,039 statin users and 1,000 statin non-users were ultimately analyzed. The patient enrolled were divided into 4 categories depending on CRP level at the time of EVT; Low-CRP (&lt;0.1 mg/dL), Intermediate-low-CRP (0.1–0.3 mg/dL), Intermediate-High-CRP (0.3–1.0 mg/dL), and High-CRP (&gt;1.0 mg/dL). A composite of death, stroke, myocardial infarction, and major amputation as the primary endpoint of this study was compared between statin users and non-users in each CRP category.

Results

The composite endpoint occurred in 255 patients during the observation period. Overall, statin users had a significantly lower event rate than non-users (Log-rank test: P&lt;0.001). However, there were no significant difference in the event rates between statin users and non-users in the Low-, and Intermediate-Low-CRP categories. Only in the Intermediate-High- and the High-CRP categories, statin users showed a significantly lower event rates than non-users (P=0.02 and P=0.008, respectively, Figures). Additionally, multivariate Cox regression analysis in the High-CRP group revealed that statin use was independently associated with the primary endpoint (adjusted hazard ratio: 0.67 [95% confidence interval: 0.45–0.99]), even after the adjustment of covariants.

Conclusion

Statins may exert a favorable prognostic effect in PAD patients with highly elevated CRP, but not in those with low to moderate CRP level.

Event free survival

Funding Acknowledgement

Type of funding source: None

Transient ischemic attack without self-awareness of symptoms witnessed by bystanders: analysis of the PROMISE-TIA registry

Background and purpose

A transient ischemic attack (TIA) can occur without self‐awareness of symptoms. We aimed to investigate characteristics of patients with a tissue‐based diagnosis of TIA but having no self‐awareness of their symptoms and whose symptoms were witnessed by bystanders.

Methods

We used data from the multicenter registry of 1414 patients with a clinical diagnosis of TIA. For patients without evidence of ischemic lesions on imaging, clinical characteristics were compared between patients with and without self‐awareness of their TIA symptoms.

Results

Among 896 patients (559 men, median age of 70 years), 59 (6.6%) were unaware of their TIA symptoms, but had those symptoms witnessed by bystanders. Patients without self‐awareness of symptoms were older and more frequently female, and more likely to have previous history of stroke, premorbid disability, and atrial fibrillation, but less likely to have dyslipidemia than those with self‐awareness. Patients without self‐awareness of symptoms arrive at hospitals earlier than those with self‐awareness (P < 0.001). ABCD² score was higher in patients without self‐awareness of symptoms than those with self‐awareness (median 5 vs. 4, P = 0.002). Having no self‐awareness of symptoms was a significant predictor of ischemic stroke within 1 year after adjustment for sex, ABCD² score, and onset to arrival time (hazard ratio = 2.44, 95% confidential interval: 1.10–4.83), but was not significant after further adjustment for arterial stenosis or occlusion.

Conclusions

Patients with a TIA but having no self‐awareness of their symptoms might have higher risk of subsequent ischemic stroke rather than those with self‐awareness, suggesting urgent management is needed even if patients have no self‐awareness of symptoms.

Surgical treatment for chronic pancreatitis: A single-center retrospective study in Japan

BACKGROUND/PURPOSE

To determine the short- and long-term results of surgical treatments for chronic pancreatitis (CP) at a high-volume center in Japan.

METHODS

The records of 151 consecutive patients undergoing surgery for CP were retrospectively reviewed. Selection of surgical procedures used had been according to the Japanese Clinical Practice Guidelines for CP 2015. Long-term (≥1 year) follow-up was performed in 100 patients (median of 37 months).

RESULTS

Surgical drainage procedures were performed in 107 patients (Frey operation in 81, longitudinal pancreaticojejunostomy in 26), pancreatic resection in 37 (subtotal stomach-preserving pancreaticoduodenectomy in 11, distal pancreatectomy in 26), and other procedures in six. The rates of postoperative mortality and morbidity were 1% and 26%, respectively. The rates of complete and partial pain relief were 62% and 37%. The frequency of occurrence of severe morbidity was significantly higher after pancreatic resection than in patients receiving drainage procedures (13% vs 2%, P = .019). The rate of new-onset diabetes was also significantly higher after resection than drainage (60% vs 25%, P = .017).

CONCLUSIONS

Surgical treatment for painful chronic pancreatitis can be safe and effective. An optimal procedure should guarantee pain relief and preserve a maximum of pancreatic function.

Conversion to open laparotomy during laparoscopic distal pancreatectomy: lessons from a single-center experience in 70 consecutive patients

PURPOSE

The purpose of this study was to determine the factors influencing conversion from laparoscopic distal pancreatectomy (LDP) to open surgery, and the effect of such conversion on the outcome.

METHODS

This retrospective single-center study included 70 consecutive patients undergoing LDP. The primary endpoint was the rate of conversion to open surgery during LDP. The secondary endpoints were determining the reasons for conversion to open surgery, with detailed analyses of these cases and a comparison of the surgical outcome with and without conversion.

RESULTS

Seven patients (10%) required conversion to open surgery during LDP. Pancreatic ductal adenocarcinoma (PDAC) was identified as a risk factor for conversion (p = 0.010). The reasons for conversion included technical difficulty (two bleeding, one severe adhesion) and pancreatic stump-related issues (two margin-positive, two stapling failures). Although the overall morbidity rate (29 vs. 11%, p = 0.48) and the rate of clinically relevant postoperative pancreatic fistula (14 vs. 5%, p = 0.82) were no different for the patients with or without open conversion, the postoperative hospital stay was significantly longer in the former (median 15 vs. 10 days, p = 0.03).

CONCLUSIONS

Careful preoperative assessment is required when planning LDP for PDAC. Although conversion to open surgery does not result in failure of LDP, efforts to reduce the duration of postoperative hospital stay and the occurrence of complications are desirable to improve the outcome of LDP.

Current Driven Tricritical Point in Large-N_{c} Gauge Theory

We discover a new tricritical point realized only in nonequilibrium steady states, using the AdS/CFT correspondence. Our system is a (3+1)-dimensional strongly coupled large-N_{c} gauge theory. The tricritical point is associated with a chiral symmetry breaking under the presence of an electric current and a magnetic field. The critical exponents agree with those of the Landau theory of equilibrium phase transitions. This suggests that the presence of a Landau-like phenomenological theory behind our nonequilibrium phase transitions.

Enzymatic Kinetics of Solvent-free Esterification with Bio-imprinted Lipase

To avoid the use of compounds that burden the environment, a solvent-free enzymatic<br /> reaction was the focus of this study. Investigated were the catalytic activities and kinetics of lipases that were pretreated with carboxylic acids for the solvent-free esterification of propionic acid with isoamyl alcohol. The enhancements of the esterification yields and rates by the bio-imprinting effects of carboxylic acids were observed. We found no inhibition of isoamyl alcohol on the solvent-free enzymatic esterification, and obtained a large imprinting effect under a largely excessive amount of isoamyl alcohol to propionic acid. From the kinetic analysis, the imprinting of lipases mainly enhanced the catalytic reaction rate constant rather than the affinity between lipase and propionic acid compared with untreated lipase. The bio-imprinting treatment of lipase is found to be very effective for the yield and kinetics in solvent-free esterification.

[A Case of Emergency Pancreaticoduodenectomy for Tumor Bleeding in Duodenal Cancer with Multiple Liver Metastases]

A 62 year-old female presenting with shortness of breath and severe anemia(Hb level 4.4 g/dL)was diagnosed with tumor bleeding and duodenal cancer by gastrointestinal endoscopy.Computed tomography scan revealed multiple liver metastases.After admission, the Hb level dropped from 9.1 g/dL to 5.1 g/dL in one night, and emergency pancreaticoduodenectomy( PD)was performed to control the bleeding.The postoperative course was uneventful, and the patient was discharged on postoperative day(POD)16.Systemic chemotherapy was initiated 1 month after surgery, but the patient died from the disease 13 months after surgery.Emergency PD could be a treatment option in patients with uncontrolled tumor bleeding and fatal conditions.

Identification of aberrant subvesical bile duct by using intraoperative fluorescent cholangiography: A case report

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Aberrant subvesical bile duct poses risk of bile duct injury during cholecystectomy.

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Intraoperative fluorescent cholangiography (IFC) could allow us to identify a fine minute bile duct.

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IFC is one of a promising technique to improve the safety of cholecystectomy further.

Introduction

Aberrant subvesical bile ducts are rare structural anomaly located in the peri-hepatic gallbladder fossa. This duct poses the risk for intraoperative bile duct injury resulting in clinically relevant bile leakage.

Presentation of case

Aberrant subvesical bile duct was detected by preoperative magnetic resonance cholangiopancreatography in a 52-year old woman with gallbladder polypoid tumor harboring the risk to be gallbladder cancer. During open cholecystectomy with full thickness dissection, the aberrant duct was identified by intraoperative fluorescent cholangiography (IFC), and dissected safely.

Discussion

Aberrant subvesical bile ducts are mostly found unexpectedly as intra and/or postoperative bile leakage, and remain an important cause of bile duct injuries after laparoscopic cholecystectomy. IFC, which offers real-time imaging of biliary anatomy, has a potential to overcome these problems.

Conclusion

We performed cholecystectomy by using IFC to identify the aberrant subvesical bile duct. To the best of our knowledge, this is the first report showing the fluorescence image of an aberrant subvesical bile duct in a state of nature.

Influence of the trapeziometacarpal joint fusion on thumb muscles and thumb-tip movement: A cadaveric study

BACKGROUND

Trapeziometacarpal (TMC) arthrodesis provides stability and strength of the thumb, whereas fixation of the TMC joint restricts motion of the thumb, which may consequently impair the activity of daily living. The objective of our study was to investigate how length and area of the thumb-tip trajectory were reduced after the TMC joint fusion.

METHODS

Six fresh, frozen cadavers were used for this study. Tension was applied to the distal tendons of 4 extrinsic thumb muscles (extensor pollicis longus, flexor pollicis longus, abductor pollicis longus, and extensor pollicis brevis) by servomotor, whereas tension was applied to 4 intrinsic muscles (abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, and adductor pollicis) using static weights. The thumb-tip trajectory was examined using a motion capture system without tension and with 5 different weights to induce intrinsic muscle tension before and after the TMC joint fusion.

FINDINGS

When tension was applied to the intrinsic muscles, the length of the thumb-tip trajectory decreased in all conditions compared with that before the TMC joint fusion, whereas the trajectory decreased only when the abductor pollicis longus was pulled. The overall thumb-tip trajectory area was reduced to approximately 30% compared with that before the TMC joint fusion.

INTERPRETATION

Thumb-tip trajectory was restricted by the TMC joint fusion to approximately 30%. However, the reduced area was found tolerable for performing daily activities. Thus, arthrodesis can be the first-line treatment in patients who wish to engage in activities of daily living without difficulties.

Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis

BACKGROUND

The frequency of liver resection in elderly patients has been increasing. However, data are limited regarding the safety of laparoscopic liver resection (LLR) compared with that of open liver resection (OLR) for hepatocellular carcinoma (HCC) in elderly patients. The present study aimed to compare short-term outcomes between LLR and OLR in elderly patients with HCC using propensity score matching.

METHODS

The study included 630 patients (age, ≥ 75 years) who underwent liver resection for HCC at nine liver centres between April 2010 and December 2017. Patients were divided into LLR and OLR groups, and perioperative outcomes were compared between the groups. In addition, subgroup analysis was performed according to age (75-79 and ≥ 80 years).

RESULTS

Of the 630 patients, 221 and 409 were included in the LLR and OLR groups, respectively. After propensity score matching, 155 patients were included in each group. Intraoperative blood loss and the transfusion, post-operative overall complication and major complication rates were lower in the matched LLR than the matched OLR group (P < 0.001, P = 0.004, P < 0.001 and P < 0.001, respectively). Moreover, post-operative pulmonary and cardiovascular complications were less frequent in the matched LLR group (P = 0.008 and P = 0.014, respectively). In subgroup analysis, among octogenarians, the post-operative major complication rate was lower and hospital stay was shorter in the matched LLR than the matched OLR group (P < 0.001 and P < 0.001, respectively).

CONCLUSION

LLR for HCC is associated with good short-term outcomes in patients aged ≥ 75 years compared with OLR. LLR is safe and feasible in selected octogenarians with HCC.

Abstract P3-03-35: Prevalence and risk factors associated with development of lymphedema after axillary lymph node dissection among breast cancer patients: Single center retrospective study

Background: Lymphedema in breast cancer is one of the most important complications, and causes symptoms of arm swelling, heaviness and limited movement. Once lymphedema has occurred, it is difficult to cure. Nowadays, treatment with axillary lymph node dissection (ALND) has been decreasing among breast cancer patients as a result of the ACOSOG Z0011, AMAROS and IBCSG 23-01 trials. However, some cases require ALND for ALN metastasis. ALND increases the risk of lymphedema and detracts from quality of life, but the surgical procedure based on anatomical landmarks has not been changed for several decades. The upper borderline for ALND might cause injury to lymph ducts from arms, and incidence and risk factors for lymphedema after ALND are still unclear. Our aim was to identify prevalence and risk factors associated with development of lymphedema after ALND among breast cancer patients.

Methods: This retrospective study was based on data collected from 178 breast cancer patients who underwent ALND in Nagasaki University Hospital, Japan, between 2005 and 2017. Lymphedema was defined as symptomatic arm swelling with &gt;2 cm difference in circumference of the arm compared with that of the contralateral arm. We classified the patients with and without lymphedema, and compared them regarding surgical and pathological findings. Univariate and multivariate analyses were performed to evaluate the risk factors, using the χ2 test, Student's t-test and Cox logistic regression analysis.

Results: Prevalence of lymphedema was 16% (28/178 patients) and mean time interval from surgery to development of lymphedema was 463 days. In univariate analysis, there was a significant difference in postmastectomy radiation therapy (PMRT) (p = 0.02) and the number of patients with &gt;18 dissected ALNs (p = 0.02). Body mass index (p = 0.6), administration of docetaxel (p = 0.2), and smoking (p = 0.07) did not significantly increase lymphedema. In multivariate analysis, PMRT (p = 0.01) and dissection of &gt;18 ALNs (p = 0.001) significantly increased the risk of lymphedema, whereas smoking did not (p = 0.4).

Conclusion: Our study suggested that PMRT and number of dissected ALNs were risk factors for lymphedema. Aggressive and empiric ALND might be associated with axillary lymph duct damage. Therefore, we plan to introduce axillary reverse mapping using indocyanine green to reduce the risk of lymphedema in breast cancer patients who undergo ALND.

Citation Format: Hara Y, Otsubo R, Inamasu E, Matsumoto M, Yano H, Sakimura C, Kuba S, Yamanouchi K, Eguchi S, Nagayasu T. Prevalence and risk factors associated with development of lymphedema after axillary lymph node dissection among breast cancer patients: Single center retrospective study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-35.

Extraction Mechanism of Ferric and Manganese Ions with Aqueous Two-phase System Formed by Ionic Liquid and Polyethylene Glycol

In this work, we employed an aqueous two-phase system formed by an ionic liquid and polyethylene glycol for the separation of Fe(III), which is the most commonly used metal in the world, and Mn(II), which is currently used in many industries. We found that the extraction mechanisms of Fe(III) and Mn(II) were strongly influenced by the concentration of the hydrochloric acid that dissolved the metal salt. The ion pair reaction was the predominant mechanism that generated the Fe(III) and Mn(II) extractions. At a lower concentration of hydrochloric acid, metal ions were extracted because of the reaction between a metal cation and a dodecylsulfonate anion. At a higher concentration of hydrochloric acid, the reaction between a metal chlorocomplex anion and a hexylmethylimidazolium cation also proceeded. The aqueous two-phase system, composed of ionic liquid and polyethylene glycol, is promising for metal separation based on the difference in the affinity of metal with alkyl-sulfonate in a low HCl concentration and in the stability constant of metal chlorocomplex in a high HCl concentration. The maximum extractability of Fe(III) and Mn(III) was 57.8 and 75.3 %, respectively, with 0.3 mol dm–3 hydrochloric acid concentration.

Thermoelectric properties of dispersant-free semiconducting single-walled carbon nanotubes sorted by a flavin extraction method

Flavin extraction method realized an improved power factor by easy removal of the dispersant from semiconducting SWNT sheet.