Engineering of IF1 -susceptive bacterial F1 -ATPase.

IF1 , an inhibitor protein of mitochondrial ATP synthase, suppresses ATP hydrolytic activity of F1 . One of the unique features of IF1 is the selective inhibition in mitochondrial F1 (MF1 ); it inhibits catalysis of MF1 but does not affect F1 with bacterial origin despite high sequence homology between MF1 and bacterial F1 . Here, we aimed to engineer thermophilic Bacillus F1 (TF1 ) to confer the susceptibility to IF1 for elucidating the molecular mechanism of selective inhibition of IF1 . We first examined the IF1 -susceptibility of hybrid F1 s, composed of each subunit originating from bovine MF1 (bMF1 ) or TF1 . It was clearly shown that only the hybrid with the ß subunit of mitochondrial origin has the IF1 -susceptibility. Based on structural analysis and sequence alignment of bMF1 and TF1 , the five non-conserved residues on the C-terminus of the ß subunit were identified as the candidate responsible for the IF1 -susceptibility. These residues in TF1 were substituted with the bMF1 residues. The resultant mutant TF1 showed evident IF1 -susceptibility. Reversely, we examined the bMF1 mutant with TF1 residues at the corresponding sites, which showed significant suppression of IF1 -susceptibility, confirming the critical role of these residues. We also tested additional three substitutions with bMF1 residues in α and γ subunits that further enhanced the IF1 -susceptibility, suggesting the additive role of these residues. We discuss the molecular mechanism by which IF1 specifically recognizes F1 with mitochondrial origin, based on the present result and the structure of F1 -IF1 complex. These findings would help the development of the inhibitors targeting bacterial F1 .

Extracting Higher Central Charge from a Single Wave Function.

A (2+1)D topologically ordered phase may or may not have a gappable edge, even if its chiral central charge c_{-} is vanishing. Recently, it was discovered that a quantity regarded as a "higher" version of chiral central charge gives a further obstruction beyond c_{-} to gapping out the edge. In this Letter, we show that the higher central charges can be characterized by the expectation value of the partial rotation operator acting on the wave function of the topologically ordered state. This allows us to extract the higher central charge from a single wave function, which can be evaluated on a quantum computer. Our characterization of the higher central charge is analytically derived from the modular properties of edge conformal field theory, as well as the numerical results with the ν=1/2 bosonic Laughlin state and the non-Abelian gapped phase of the Kitaev honeycomb model, which corresponds to U(1)_{2} and Ising topological order, respectively. The Letter establishes a numerical method to obtain a set of obstructions to the gappable edge of (2+1)D bosonic topological order beyond c_{-}, which enables us to completely determine if a (2+1)D bosonic Abelian topological order has a gappable edge or not. We also point out that the expectation values of the partial rotation on a single wave function put a constraint on the low-energy spectrum of the bulk-boundary system of (2+1)D bosonic topological order, reminiscent of the Lieb-Schultz-Mattis-type theorems.

Complete Crystalline Topological Invariants from Partial Rotations in (2+1)D Invertible Fermionic States and Hofstadter's Butterfly.

The theory of topological phases of matter predicts invariants protected only by crystalline symmetry, yet it has been unclear how to extract these from microscopic calculations in general. Here, we show how to extract a set of many-body invariants {Θ_{o}^{±}}, where o is a high symmetry point, from partial rotations in (2+1)D invertible fermionic states. Our results apply in the presence of magnetic field and Chern number C≠0, in contrast to previous work. {Θ_{o}^{±}} together with C, chiral central charge c_{-}, and filling ν provide a complete many-body characterization of the topological state with symmetry group G=U(1)×_{ϕ}[Z^{2}⋊Z_{M}]. Moreover, all these many-body invariants can be obtained from a single bulk ground state, without inserting additional defects. We perform numerical computations on the square lattice Hofstadter model. Remarkably, these match calculations from conformal and topological field theory, where G-crossed modular S, T matrices of symmetry defects play a crucial role. Our results provide additional colorings of Hofstadter's butterfly, extending recently discovered colorings by the discrete shift and quantized charge polarization.

Effects of Material Structure on Stress Relaxation Characteristics of Rapidly Solidified Al-Fe Alloy.

An Al-Fe alloy which was produced by hot extrusion of rapidly solidified powder is a possible solution to substitute copper-based electrical conductor material due to its high strength and high electrical conductivity. However, the stress relaxation characteristic-an essential parameter as a conductor material-and the effect of the material structure have not been reported, which was the aim of the present paper. An Al-5%Fe alloy was selected as the test material. The material structures were controlled by hot extrusion practice, annealing, and cold rolling. The Al-Fe intermetallic compound particles controlled the residual stress after the stress relaxation test via the Orowan mechanism. Decreasing the mean inter-particle distance reduces the electrical conductivity. The increase in the number of dislocations by the cold rolling increased strength at room temperature without changing electrical conductivity; however, it did not have a positive effect on the stress relaxation characteristics. The stress relaxation characteristics and the electrical conductivity of the Al-Fe alloy were superior to conventional C52100 H04 phosphor bronze when compared with the case of the same mass.

Effects of Hot Extrusion Temperature Conditions on the Hardness and Electrical Conductivity of Rapidly Solidified Al-Fe Alloys.

Rapidly solidified Al-Fe alloys produced by hot extrusion are a promising replacement for copper-based electrical conductors because of their light weight. However, the effects of the extrusion temperature conditions on the mechanical and electrical properties of extruded materials are unknown. The present work investigated the effects of billet preheating temperature, in situ temperature during extrusion, and additional heat treatment after extrusion on hardness and electrical conductivity. An air-jet atomized Al-2.3%Fe alloy powder was pre-sintered into cylindrical billets and then hot-extruded. The hardness of the extrudates decreased as the in situ temperature during extrusion increased above 650 K. The billet preheating temperature affected the in situ temperature during extrusion. Additional annealing after extrusion decreased the hardness. The cause of the decrease in hardness was coarsening of the grain of the aluminum matrix. The electrical conductivity increased with higher billet preheating temperatures before extrusion or additional annealing after extrusion; however, an in situ temperature rise for a few seconds during extrusion did not affect the conductivity. The increase in electrical conductivity was considered to be caused by a decrease in the amount of solute iron, which requires holding the material at a high temperature for longer than several minutes.

Anticoagulation against portal vein thrombosis reduces mortality and liver cirrhosis-related complications: A propensity score-matched study.

AIM: Portal vein thrombosis (PVT) is one of the common complications of liver cirrhosis. Although anticoagulation contributes to thrombus resolution and is considered the first-choice treatment, its impact on patients' prognosis is still controversial. This study aimed to clarify the benefit of anticoagulation on mortality, liver function, and the incidence of liver cirrhosis-related complications in cirrhotic PVT patients. METHODS: We conducted a multicenter retrospective review in which we included 78 eligible patients with PVT out of 439. After propensity score matching, 21 cirrhotic PVT patients were included in each one of the untreated control and anticoagulation groups. RESULTS: Overall survival was significantly improved in the anticoagulation group compared with the control group (p = 0.041), along with PVT size reduction (53.3% vs. 108.2%, p = 0.009). At the time of CT follow-up, the anticoagulation group showed a lower ALBI score (p = 0.037) and its prevalence of massive ascites was significantly lower (p = 0.043) compared with the control group. The incidence of overt encephalopathy was also lower in the anticoagulation group (p = 0.041). The cumulative incidence of bleeding events did not differ significantly between the two groups. CONCLUSIONS: Anticoagulation improves the survival of patients with cirrhotic PVT. Preserved liver function and reduced risks of cirrhosis-related complications under the treatment may have contributed to a better prognosis. Given its efficacy and safety, anticoagulation is worth initiating in patients with PVT.

Rotary properties of hybrid F1-ATPases consisting of subunits from different species.

F1-ATPase (F1) is an ATP-driven rotary motor protein ubiquitously found in many species as the catalytic portion of FoF1-ATP synthase. Despite the highly conserved amino acid sequence of the catalytic core subunits: α and ß, F1 shows diversity in the maximum catalytic turnover rate Vmax and the number of rotary steps per turn. To study the design principle of F1, we prepared eight hybrid F1s composed of subunits from two of three genuine F1s: thermophilic Bacillus PS3 (TF1), bovine mitochondria (bMF1), and Paracoccus denitrificans (PdF1), differing in the Vmax and the number of rotary steps. The Vmax of the hybrids can be well fitted by a quadratic model highlighting the dominant roles of ß and the couplings between α-ß. Although there exist no simple rules on which subunit dominantly determines the number of steps, our findings show that the stepping behavior is characterized by the combination of all subunits.

Molecular mechanism on forcible ejection of ATPase inhibitory factor 1 from mitochondrial ATP synthase.

IF1 is a natural inhibitor protein for mitochondrial FoF1 ATP synthase that blocks catalysis and rotation of the F1 by deeply inserting its N-terminal helices into F1. A unique feature of IF1 is condition-dependent inhibition; although IF1 inhibits ATP hydrolysis by F1, IF1 inhibition is relieved under ATP synthesis conditions. To elucidate this condition-dependent inhibition mechanism, we have performed single-molecule manipulation experiments on IF1-inhibited bovine mitochondrial F1 (bMF1). The results show that IF1-inhibited F1 is efficiently activated only when F1 is rotated in the clockwise (ATP synthesis) direction, but not in the counterclockwise direction. The observed rotational-direction-dependent activation explains the condition-dependent mechanism of IF1 inhibition. Investigation of mutant IF1 with N-terminal truncations shows that the interaction with the γ subunit at the N-terminal regions is crucial for rotational-direction-dependent ejection, and the middle long helix is responsible for the inhibition of F1.

Malignant potential and specific characteristics of pure main duct type intraductal papillary mucinous neoplasm.

BACKGROUND: As the malignant potential of main duct (MD-) type intraductal papillary mucinous neoplasm (IPMN) has been discussed together with Mixed-type in most previous studies, the malignant potential of pure MD-type IPMN remains unclear. This study evaluated the specific characteristics and predictors of high-grade dysplasia (HGD) and invasive intraductal papillary mucinous carcinoma (IPMC) for pure MD-type IPMN. METHODS: From 1,100 patients with IPMN, this study includes 387 patients that underwent surgery. We evaluated the specific characteristics of pure MD-type IPMN by comparing clinicopathological factors between MD-type (n = 79) and branch duct (BD-) type (n = 146) or Mixed-type IPMN (n = 162), and predictors of HGD/invasive IPMC in pure MD-type IPMN. RESULTS: The rate of HGD/invasive IPMC was significantly higher in MD-type than in BD-type (70.9 vs. 48.6%, P = 0.001), although there was no difference between MD-type and Mixed-type IPMNs (P = 0.343). Recurrence-free survival (RFS) and disease-specific survival (DSS) of patients with MD-type were better than those of patients with Mixed-type (P = 0.008 and P = 0.009, respectively). There were no significant differences in RFS, overall survival, and DSS between patients with MD-type and patients with BD-type IPMNs. Multivariate analysis showed two independent predictors of HGD/invasive IPMC in MD-type IPMN; mural nodule height ≥5 mm (P = 0.025, odds ratio [OR]; 16.949) and carcinoembryonic antigen (CEA) level in the pancreatic juice obtained by preoperative endoscopic retrograde pancreatography ≥50 ng/ml (P = 0.039, OR; 9.091). CONCLUSIONS: Measurement of mural nodule height and CEA in the pancreatic juice might be useful in determining surgical indication for pure MD-type IPMN, although further studies for confirmation are essential.

Pancreatectomy With Artery En-bloc Resection for Pancreatic Neck/Body Cancer: A Single-arm Pilot Study.

BACKGROUND/AIM: The potential benefits of pancreatectomy with major arterial resection have been studied in the past, but findings remain controversial. Pancreatic neck/body cancer (PNBC) involving arteries frequently requires combined resection of the pancreas, artery and portal vein. PATIENTS AND METHODS: Nine prospectively-registered consecutive patients with PNBC were enrolled, all underwent pancreatoduodenectomy with common hepatic artery en-bloc resection (PD-CHAR). We investigated the safety of PD-CHAR by blood flow evaluation with intraoperative indocyanine green fluorescence imaging in reconstructed vessels/organs. RESULTS: Among patients who underwent PD-CHAR, there was no severe morbidity. Artery/portal vein combined resection and reconstruction was performed in all patients. Four (44%) patients had pathological positivity for cancer cell invasion into the nerve plexus of artery at the site of radiographic artery involvement, although one (11%) was diagnosed with pathological artery involvement. CONCLUSION: PD-CHAR following neoadjuvant therapy might be feasible for PNBC without severe postoperative complications. Survival benefits in PNBC should be confirmed in further studies.

The effects of choreito on a model of nocturnal polyuria using Dahl salt-sensitive rats.

OBJECTIVES: This study aimed to determine whether Dahl salt-sensitive rats fed a high-salt diet would show features of nocturia due to nocturnal polyuria and to examine the efficacy of choreito (CRT) on nocturnal polyuria. METHODS: Dahl salt-sensitive rats were divided into three groups. Group A was fed a 4% salt diet, group B a 2% salt diet, and group C a normal 0.3% salt diet. In groups α and ß, other rats were further divided into two groups: The rats in group α were fed a 2% salt plus 3% CRT diet, and those in group ß, were fed a 2% salt diet. Each rat was placed in an individual metabolic cage for 24 hours every week for 6 weeks. Water intake, urine production, voiding frequency, and voided volume per micturition were recorded. RESULTS: The systolic blood pressure increased in the group fed a 4% salt diet compared to groups fed with a 2% and 0.3% salt diet. The urinary volume was higher in the groups fed with 4% and 2% salt than in the group fed with 0.3% salt. Further, water intake in the group fed a 2% salt plus 3% CRT diet was significantly lower than that in the group fed with a 2% salt diet. CONCLUSIONS: Dahl salt-sensitive rats fed a 2% salt diet were candidates for a model of nocturnal polyuria. Using this model, we suggest that CRT reduces water intake in the active phase and contributes to water restriction in the treatment of nocturnal polyuria.

Previous upper abdominal surgery is a risk factor for nasogastric tube reinsertion after pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy without subsequent nasogastric tube management has not been widely adopted due to delayed gastric emptying, the specific and frequent morbidity associated with this surgical procedure. We assessed the feasibility of pancreaticoduodenectomy without use of nasogastric tubes and the risk factors for subsequent nasogastric tube reinsertion. METHODS: We retrospectively reviewed 465 patients who underwent pancreaticoduodenectomy at a single institution between 2010 and 2019. Primary endpoint was the rate of nasogastric tube reinsertion. Logistic regression analysis was used to determine independent risk factors of nasogastric tube reinsertion and delayed gastric emptying. RESULTS: The rate of nasogastric tube reinsertion was 10.1% (47/465). The rate of delayed gastric emptying was 9.5% (44/465). Logistic regression analysis identified 4 independent risk factors for nasogastric tube reinsertion: male sex (odds ratio = 4.42; 95% confidence interval 1.50-13.0, P = .007), comorbidity of cardiac ischemia (odds ratio = 3.04; 95% confidence interval 1.05-8.79, P = .041), preoperative cholangitis or cholecystitis (odds ratio = 2.21; 95% confidence interval 1.02-4.76, P = .044), and previous upper abdominal surgery (odds ratio = 8.34; 95% confidence interval 3.07-22.7, P < .001). Independent risk factors for delayed gastric emptying were male sex (odds ratio = 3.20; 95% confidence interval 1.11-9.21, P = .031), comorbidity of cardiac ischemia (odds ratio = 3.81; 95% confidence interval 1.34-10.8, P = .012), concomitant organ resection (odds ratio = 3.99; 95% confidence interval 1.10-14.4, P = .035), and previous upper abdominal surgery (odds ratio = 7.21; 95% confidence interval 2.68-19.4, P < .001). CONCLUSION: Pancreaticoduodenectomy without use of nasogastric tubes is feasible, but patients with previous upper abdominal surgery require careful postoperative nasogastric tube management.

Kinetic analysis of the inhibition mechanism of bovine mitochondrial F1-ATPase inhibitory protein using biochemical assay.

ATPase inhibitory factor 1 (IF1) is a mitochondrial regulatory protein that blocks ATP hydrolysis of F1-ATPase, by inserting its N-terminus into the rotor-stator interface of F1-ATPase. Although previous studies have proposed a two-step model for IF1-mediated inhibition, the underlying molecular mechanism remains unclear. Here, we analysed the kinetics of IF1-mediated inhibition under a wide range of [ATP]s and [IF1]s, using bovine mitochondrial IF1 and F1-ATPase. Typical hyperbolic curves of inhibition rates with [IF1]s were observed at all [ATP]s tested, suggesting a two-step mechanism: the initial association of IF1 to F1-ATPase and the locking process, where IF1 blocks rotation by inserting its N-terminus. The initial association was dependent on ATP. Considering two principal rotation dwells, binding dwell and catalytic dwell, in F1-ATPase, this result means that IF1 associates with F1-ATPase in the catalytic-waiting state. In contrast, the isomerization process to the locking state was almost independent of ATP, suggesting that it is also independent of the F1-ATPase state. Further, we investigated the role of Glu30 or Tyr33 of IF1 in the two-step mechanism. Kinetic analysis showed that Glu30 is involved in the isomerization, whereas Tyr33 contributes to the initial association. Based on these findings, we propose an IF1-mediated inhibition scheme.

Division of the pancreas at the neck reduces postoperative pancreatic fistula in laparoscopic distal pancreatectomy: Comparison of pancreatic division at the body.

BACKGROUND: objectives: During laparoscopic distal pancreatectomy (LDP), the optimal site for pancreatic division with consideration of postoperative pancreatic fistula (POPF) is unclear. We evaluate which site of pancreatic division, neck or body, has better outcomes after LDP. METHODS: This was a retrospective, observational study. LDP was performed in 102 consecutive patients between December 2009 and May 2020. After excluding 14 patients with pancreatic division at tail, 88 patients (pancreatic division at neck n = 46, at body n = 42) were included in this study. Short- and long-term outcomes after LDP were compared between pancreatic division at neck and body. RESULTS: The pancreatic transection site was thicker at body than at neck (17.5 vs. 11.9 mm, P < 0.001), although there were no significant differences of pancreatic texture and pancreatic duct size. The Grade B/C POPF rate was significantly higher when the pancreas was divided at body than when divided at neck (21.4 vs. 6.5%, P = 0.042). We found no significant differences between pancreatic division at neck and body in residual pancreatic volume (34.0 vs. 34.8 ml, P = 0.855), incidence of new-onset or worsening diabetes mellitus more than six months after LDP (P = 0.218), or body weight change (six-month: P = 0.116, one-year: P = 0.108, two-year: P = 0.195, tree-year: P = 0.131, four-year: P = 0.608, five-year: P = 0.408). CONCLUSION: This study suggests that the pancreatic division at neck might reduce the Grade B/C POPF incidence after LDP, compared to division at body. A potential reason is that the pancreas at body is thicker than that at neck. However, further large-scale studies are necessary to confirm our results.

Thyroid function in patients with selenium deficiency exhibits high free T4 to T3 ratio.

Selenium, one of the essential trace minerals, is present in vivo in form of selenoproteins. Iodothyronine deiodinase, a selenoprotein, is involved in the activation and inactivation of thyroid hormone. Therefore, patients with selenium deficiency may present changes in thyroid hormone levels due to inhibition of T4 to T3 conversion; however, this assumption is still under debate. In the present study, we retrospectively investigated the thyroid function in 22 patients with selenium deficiency. Thyroid stimulating hormone (TSH) and free T4 (FT4) levels were increased in 3 (14%) and 5 (23%) patients, respectively, and free T3 (FT3) levels were decreased in 6 (27%) patients. The FT4/FT3 ratio was significantly higher in patients with selenium deficiency than that in the control group. There appeared to be a positive correlation between the decreased rate of selenium levels and FT4/FT3 ratio, thereby indicating that patients with severe selenium deficiency also exhibited abnormal thyroid hormone levels. Furthermore, when selenium was supplemented in seven patients with abnormal thyroid hormone levels, the TSH, FT4, and FT4/FT3 ratio were significantly decreased and FT3 levels were increased. Collectively, patients with selenium deficiency could present the characteristics of not only low FT3 but also high FT4 and FT4/FT3 ratio.

Radiographic Splenic Artery Involvement Is a Poor Prognostic Factor in Upfront Surgery for Patients with Resectable Pancreatic Body and Tail Cancer.

PURPOSE: The prognostic impact of radiographic splenic vessel involvement in pancreatic cancer remains unclear. We evaluate its oncological significance in resectable pancreatic body/tail cancer. PATIENTS AND METHODS: We retrospectively review 102 cases of resectable pancreatic cancer and 51 of borderline resectable pancreatic cancer (BRPC) who underwent pancreatectomy for pancreatic body/tail cancer. Resectable pancreatic body/tail cancer was classified into one of three categories based on radiographic splenic vessel involvement. RESULTS: Among 102 cases of resectable pancreatic cancer, 37 (36.3%), 35 (34.3%), and 30 cases (29.4%) were classified as no splenic vessel involvement (Rnone), splenic vein involvement (RV), and splenic artery involvement (RA), respectively. Disease-free survival (DFS) among patients with Rnone, RV, RA, and BRPC was 58.5, 18.4, 10.8, and 9.2 months, respectively. Patients with RV and RA had significantly poorer DFS than patients with Rnone (P = 0.010, P < 0.001, respectively). Median survival among Rnone, RV, RA, and BRPC was 80.6, 23.4, 15.1, and 21.3 months, respectively. Patients with RV and RA had significantly poorer survival than patients with Rnone (P = 0.001, P < 0.001, respectively) and had short survival similar to that of those with BRPC. Multivariate Cox proportional hazard analysis detected preoperative CA19-9 ≥ 37 IU/L, radiologic splenic vein involvement, radiologic splenic artery involvement, intraoperative bleeding ≥ 500 ml, transfusion, positive washing cytology, and noncompletion of adjuvant therapy as independent prognostic factors. CONCLUSIONS: Radiographic splenic artery involvement is a poor prognostic factor in resectable pancreatic body/tail cancer and may have a role in stratification of treatment strategy.

Surgical indication for intraductal papillary mucinous neoplasm without mural nodule ≥5 mm.

BACKGROUND: In intraductal papillary mucinous neoplasm, a mural nodule ≥5 mm is an important predictor of malignancy. Surgical indication is less clear in cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. This is a retrospective study evaluating predictors of high-grade dysplasia or invasive intraductal papillary mucinous carcinoma for intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. METHODS: Among consecutive patients who underwent surgery for intraductal papillary mucinous neoplasm between 1999 and 2018, 174 had intraductal papillary mucinous neoplasm with mural nodule ≥5 mm (mural nodule[+] ≥5 mm group). The remaining 155 patients had intraductal papillary mucinous neoplasm but did not have mural nodule ≥5 mm: 24 patients with mural nodule <5 mm (mural nodule[+] <5 mm group) and 131 patients without mural nodule (mural nodule[-] group). We investigated predictors of high-grade dysplasia or invasive intraductal papillary mucinous neoplasm in cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. RESULTS: The frequency of high-grade dysplasia invasive intraductal papillary mucinous neoplasm was significantly higher in the mural nodule(+) ≥5 mm group (87.4%) than in the mural nodule(+) <5 mm group (37.5%, P < .001) and mural nodule(-) group (45.0%, P < .001). However, frequency was not significantly different between mural nodule(+) <5 mm and mural nodule(-) groups (P = .494). Multivariate analysis showed three independent predictors of high-grade dysplasia invasive intraductal papillary mucinous carcinoma in intraductal papillary mucinous neoplasm without mural nodule ≥5 mm: branch cyst ≥40 mm (P = .038, odds ratio 3.704; 95% confidence interval, 1.075-12.821), positive cytology of pancreatic juice (P = .039, odds ratio 16.792; 95% confidence interval, 1.152-244.744), and carcinoembryonic antigen in pancreatic juice ≥30 mg/mL (P < .001, odds ratio 14.925; 95% confidence interval, 4.525-50.0). CONCLUSION: For cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm, large cysts, positive cytology of the pancreatic juice, and high levels of carcinoembryonic antigen in pancreatic juice may be useful to determine surgical indication, although further studies are needed to confirm these results.

Impact of Ninjin'Yoeito on Fatigue in Patients Receiving Nab-Paclitaxel Plus Gemcitabine Therapy: A Prospective, Single-Arm, Phase II Open Label, Nonrandomized, Historically-Controlled Study.

BACKGROUND: Ninjin'yoeito, a traditional Japanese herbal medicine, is used to prevent fatigue, loss of appetite, and coldness of limbs. Fatigue is an especially common issue during chemotherapy and can affect quality of life and the ability to complete scheduled treatment. OBJECTIVES: This prospective exploratory trial evaluates the efficacy of ninjin'yoeito for fatigue in patients undergoing nab-paclitaxel plus gemcitabine therapy for unresectable pancreatic cancer. The primary end point was evaluation of fatigue according to Functional Assessment of Chronic Illness Therapy-Fatigue score during 2 courses of nab-paclitaxel plus gemcitabine therapy. Secondary end points included evaluation of dose intensity, appetite loss using numerical rating scale, and peripheral neuropathy using a patient neurotoxicity questionnaire. METHODS: We compared data from this interventional trial with a prior observational trial without administration of ninjin'yoeito with identical definition of end points (UMIN000021758). Thirty patients were required by the study. RESULTS: Threshold mean of Functional Assessment of Chronic Illness Therapy-Fatigue score across 8 weeks during chemotherapy was under 5.3 (P = 0.002). Secondary end points did not reveal any specific patterns in appetite loss or degree of pain. No significant changes in patient neurotoxicity questionnaire concerning sensory/motor disorders were observed, but the mean (SD) incidence of patients with sensory disturbance was higher between the fifth and eighth weeks (8.8 [1.26]) than during the first and fourth weeks (4.8 [0.96]) (P = 0.003). Clinically significant adverse reactions of ninjin'yoeito were not observed. CONCLUSIONS: Ninjin'yoeito may be useful for improving the symptoms of fatigue caused by nab-paclitaxel plus gemcitabine in patients with unresectable pancreatic cancer. UMIN Clinical Trials Registry identifier: UMIN000025606. (Curr Ther Res Clin Exp. 2020; 81:XXX-XXX).

Effective Response of Intrahepatic Cholangiocarcinoma to Pembrolizumab: A Case Report.

BACKGROUND/AIM: The efficacy of pembrolizumab for intrahepatic cholangiocellular carcinoma (IHCCC) is not widely reported. CASE REPORT: We began pembrolizumab treatment in a 69-year-old male with recurrent IHCCC at 18 months after his surgery because of the proven microsatellite instability (MSI)-high status. The patient had partial response, with an 82.5% reduction at the end of 18 courses. Immunostaining of the primary tumor revealed intra-tumoral infiltration of both PD-1+ and CD8+ T cells, and a low expression of PD-L1. CONCLUSION: Intra-tumoral infiltration of both PD-1+ and CD8+ T cells may be a predictive factor of the efficacy of pembrolizumab. Expression of PD-L1 did not correlate with a therapeutic effect, but the tumor microenvironment of our patient's recurrent lesions may have been modified by conventional chemotherapy and CD8+ T cells.

Complete REtraction of the StomaCh using pEnrose draiN and liver reTractor (CRESCENT) during laparoscopic distal pancreatectomy.

PURPOSE: Laparoscopic distal pancreatectomy (LDP) is a well-accepted procedure for benign and malignant diseases of the pancreatic body and/or tail. To perform it safely, a wide operative field is crucial. For the maintenance of a good surgical field during LDP, we developed an original technique for stomach retraction: "Complete REtraction of the StomaCh using pEnrose draiN and liver reTractor, CRESCENT." METHODS: In CRESCENT technique, the body and antrum of the stomach are suspended by two Penrose drains, and the fundus and/or upper body of the stomach are retracted upward using a liver retractor. After complete retraction, the stomach is well attached to the abdominal wall and forms a crescent-like shape. Before we developed the CRESCENT technique, we pulled the antrum of the stomach laterally by suture and hanged the body of the stomach upward using a Penrose drain (control method). We evaluated perioperative outcomes of the 87 consecutive patients who underwent LDP and compared outcomes of CRESCENT technique (n = 24) and previously used technique as a control (n = 63). RESULTS: Operative time was significantly shorter in the CRESCENT technique than in control method (median, 234 vs. 303 min, P < 0.001). We found no significant differences in incidences of overall morbidity (16.7 vs. 20.6%, P = 0.677), including grade B/C postoperative pancreatic fistula (8.3 vs. 7.9%, P = 0.455), between CRESCENT technique and control method. There was no mortality by either method. CONCLUSIONS: Our original technique, CRESCENT, is a simple procedure in which the stomach is completely retracted during LDP.