Low Serum Zinc Concentration Is Associated With Infection Particularly in Patients With Stage 5 Chronic Kidney Disease Medicated with Proton Pump Inhibitors

OBJECTIVE

Zinc (Zn) plays an important role in immune function. Several studies have identified an association between a Zn deficiency and infection. Infectious diseases are major complications of chronic kidney disease (CKD). We investigated whether serum Zn concentrations are associated with risk of infection in patients with advanced CKD.

DESIGN AND METHODS

We retrospectively analyzed data from 299 patients with CKD whose serum Zn values were measured to evaluate anemia between January 2013 and December 2016. Among them, 9 who were supplemented with Zn and 67 who had started urgent dialysis at the time of measurement were excluded. We analyzed infection events, length of infection-related hospitalization and infection-related and all-cause mortality in the remaining 223 patients during a median follow-up of 36 months. We assigned the patients to groups with low or high Zn values (≤50 and >50 μg/dL, respectively) based on a median value of 50 μg/dL. Data were analyzed using Kaplan-Meier curves and Cox hazards models.

RESULTS

During a median follow-up of 36 months, 40 patients were hospitalized with infections. The rate of infection-related and long-term hospitalization (>10 days) due to infection was higher for patients with low, than high, Zn values (23.3% vs. 12.6%; P = .042 and 26.2% vs. 12.4%; P = .007, respectively). After adjustment in Cox hazards models, low serum Zn values remained an independent risk factor for infection-related hospitalization (Hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.01-3.71; P = .048), especially for patients on proton pump inhibitor (PPI) medications (HR, 2.66, 95%; CI, 1.22-5.81; P = .014).

CONCLUSION

Patients with advanced CKD accompanied by low serum Zn concentration, and particularly those medicated with PPI, are at high risk of infection-related hospitalization, which results in long-term hospitalization.

Initial experience of virtual-assisted lung mapping utilizing both indocyanine green and indigo carmine

Virtual-assisted lung mapping is a bronchoscopic multiple dye marking technique that facilitates sublobar lung resections for unidentifiable pulmonary tumors. Marking failure reportedly occurs in 10% of cases. To overcome this limitation, we developed indocyanine green virtual-assisted lung mapping that uses indocyanine green in addition to indigo carmine. Here, we report our initial experience of indocyanine green virtual-assisted lung mapping.

The Dimeric Form of 1,3-Diaminoisoquinoline Derivative Rescued the Mis-splicing of Atp2a1 and Clcn1 Genes in Myotonic Dystrophy Type 1 Mouse Model

Expanded CUG repeat RNA in the dystrophia myotonia protein kinase (DMPK) gene causes myotonic dystrophy type 1 (DM1) and sequesters RNA processing proteins, such as the splicing factor muscleblind-like 1 protein (MBNL1). Sequestration of splicing factors results in the mis-splicing of some pre-mRNAs. Small molecules that rescue the mis-splicing in the DM1 cells have drawn attention as potential drugs to treat DM1. Herein we report a new molecule JM642 consisted of two 1,3-diaminoisoquinoline chromophores having an auxiliary aromatic unit at the C5 position. JM642 alternates the splicing pattern of the pre-mRNA of the Ldb3 gene in the DM1 cell model and Clcn1 and Atp2a1 genes in the DM1 mouse model. In vitro binding analysis by surface plasmon resonance (SPR) assay to the r(CUG) repeat and disruption of ribonuclear foci in the DM1 cell model suggested the binding of JM642 to the expanded r(CUG) repeat in vivo, eventually rescue the mis-splicing.

Intestinal echinococcosis in a dog from Missouri

CASE DESCRIPTION

A 17-week-old 14.4-kg (31.7-lb) female German Shepherd Dog from Missouri with a history of multiple intermittent episodes of vomiting and diarrhea underwent exploratory celiotomy.

CLINICAL FINDINGS

At the time of surgery, the dog was bright, alert, and responsive, with a tender abdomen and palpable mesenteric lymph nodes. Hematologic data revealed mild leukocytosis, mild hypoproteinemia, and mild hypoalbuminemia. Moderate petechiation of the jejunal serosa and prominent mesenteric lymph nodes, but no palpable obstructions, were found during surgery. Jejunal and lymph node biopsies were performed; histologic examination revealed multiple segments of adult cestodes up to 700 μm long in the jejunum. Segments had a scolex and contained approximately 30- to 35-μm-diameter ova, morphologically compatible with Echinococcus spp. Fecal flotation revealed numerous proglottids and ova similar to those recognized histologically. Results of PCR assays confirmed Echinococcus multilocularis of E4 haplotype (a European strain).

TREATMENT AND OUTCOME

Praziquantel (5 mg/kg [2.3 mg/lb], SC, once) was administered after surgery; treatments after hospital discharge included praziquantel (10 mg/kg [4.5 mg/lb], PO, once). No proglottids or ova were observed by fecal flotation after the treatments. The dog remained healthy without gastrointestinal signs 1 year later.

CLINICAL RELEVANCE

The dog of this report had no travel history outside the state of Missouri. To the authors' knowledge, this is the first report of intestinal E multilocularis infection in a pet dog in the contiguous United States and first detection of a European strain of E multilocularis in this country. Findings suggested possible establishment of a European strain of this zoonotic pathogen in the contiguous United States.

Hybrid technique of virtual-assisted lung mapping and systemic indocyanine green injection for extended segmentectomy

BACKGROUND

Various approaches have been used to assist and facilitate segmentectomy with favorable oncological outcomes. We describe a hybrid approach comprising virtual-assisted lung mapping (VAL-MAP), which is a preoperative bronchoscopic dye-marking technique, combined with systemic indocyanine green (ICG) injection.

CLINICAL PRESENTATION

An asymptomatic 64-year-old man was referred to our department because of a lung nodule detected during his annual medical checkup. The chest computed-tomography image revealed a 16-mm, partly solid, ground-glass nodule in the left segment 4. Because the nodule was hardly palpable and deeply located between the left upper division segment and the left lingular segment, we performed VAL-MAP to facilitate extended left lingulectomy. Five dye markings were undertaken preoperatively. Surgery to remove the nodule was then conducted via complete three-port video-assisted thoracic surgery. The VAL-MAP markings were easily identified intraoperatively and helped locate the nodule. The intersegmental plane was identified by the ICG injection. The resection line was determined based on the intersegmental plane identified by the ICG injection and the site of the nodule suggested by the VAL-MAP markings. Following the resection line, we thoracoscopically achieved extended lingulectomy with sufficient surgical margins. The patient was discharged with no complications. The pathological diagnosis was adenocarcinoma in situ.

CONCLUSION

The hybrid technique of VAL-MAP and systemic ICG injection can be useful for accomplishing successful extended segmentectomy.

Suppression of inflammatory genes expression in the injured host intestinal wall during Mesocestoides vogae tetrathyridium larvae migration

Mesocestoides vogae is a cestode parasite of the family Mesocestoididae (order Cyclophyllidea). Its larvae, tetrathyridium, are approximately 1 mm long and 300 μm wide and infect a wide range of host species including humans. Tetrathyridium migrate through the intestinal wall to invade the peritoneal cavity. Despite intestinal penetration by such a large-sized parasite, symptomatic intestinal disorders are not common during the migration period. In this study, the dynamics of tetrathyridia migration and their pathogenicity towards intestinal tissues were examined in mice infected orally with these parasites. Most tetrathyridia were found to migrate through the intestinal wall, moving into the peritoneal cavity or liver 24 to 48 hours after the oral infections. Next, the pathogenicity of tetrathyridium in the intestinal wall was histopathologically evaluated, and tissue injury from tetrathyridium migration was confirmed. Inflammatory foci were observed as tetrathyridium migration tracks from 48 hours after oral infection; however, the number of inflammatory foci had decreased by half more than 48 hours later. Therefore, we examined the gene expression levels of the macrophage driving cytokine, IL-1β, and the eosinophil recruiting chemokine, CCL11, by quantitative reverse-transcriptase PCR. The expression levels of these genes in the infected group were significantly lower than those of the non-infected group at 48 hours post-infection. Although the immunomodulating ability of the excretory-secretory products released from tetrathyridium has been previously shown by in vitro assays, the significance of this ability in their lifecycle has remained unclear. In this study, we discovered that tetrathyridium causes temporal inflammation in the intestinal wall during penetration and large-scale migration in this organ, but tetrathyridium simultaneously suppresses the host’s inflammatory gene expression, might to be a strategy that reduces inflammatory responses and increases survival of the parasite.

Excretory-secretory (ES) products are released by parasitic helminths into their migration sites and/or the intestinal regions they inhabit where parasite and host immune responses interact. ES products are release by a wide range of parasitic helminths, some of which are known to modulate the host’s immune system. Some ES products from some cestode parasites are known to reduce the production of pro-inflammatory cytokines from artificially stimulated cells under in vitro conditions. However, the immunomodulatory properties of the ES products have only been observed with in vitro experimental models and the biological consequences of their potential ability to suppress the host’s immune system during the parasite’s lifecycle and how they affect host–parasite interactions await discovery. Our results show that tetrathyridium, the larval stage of the Mesocestoides vogae cestode, strongly inhibits the host’s inflammatory gene expression in the injured intestinal wall, and that the inflammatory hot-spots caused by larval migration disappear almost immediately after mice are orally infected with these parasites. The ability to suppress the host’s inflammatory gene expression when larvae migrate through and damage the host’s tissues is an effective survival strategy for M. vogae intestinal parasites.

Bronchosubcutaneous fistula manifesting as massive subcutaneous emphysema treated successfully by endobronchial Watanabe spigots

A bronchosubcutaneous fistula (BF) is an abnormal communication between the bronchus, pleural cavity, and subcutaneous tissue. Treatment of BF has been documented rarely. We describe a successful endoscopic bronchial occlusion using endobronchial Watanabe spigots (EWSs) for BF manifesting as massive subcutaneous emphysema (SE). A 78-year-old woman developed delayed localized SE following a surgical pleural biopsy for the diagnosis of primary lung cancer. Computed tomography (CT) of the chest revealed BFs resulting from pleural biopsy. The affected bronchi were identified using chest CT. We inserted EWSs into the affected bronchi with the aid of virtual bronchoscopic navigation. This bronchoscopic procedure achieved complete resolution of the SE by sealing the BFs without the need for surgical interventions.

Left apicoposterior segmentectomy for lung cancer with displaced segmental bronchus: a case report

Background

Pulmonary segmentectomy can be challenging when thoracic surgeons encounter anatomical anomalies. A displaced left apicoposterior bronchus is a rare bronchial anomaly that makes lung anatomical resection challenging. We herein present a case of successful left apicoposterior segmentectomy for lung cancer in a patient with an anomalous segmental bronchus.

Case presentation

A 70-year-old man was clinically diagnosed with early-stage lung cancer for which segmentectomy was indicated. A preoperative image revealed a displaced left apicoposterior bronchus that branched behind the left main pulmonary artery. With the aid of three-dimensional reconstruction imaging and systemic indocyanine green injection, we successfully performed left apicoposterior segmentectomy under complete video-assisted thoracic surgery. The pathological diagnosis was adenocarcinoma. The patient was alive without recurrence 8 months after segmentectomy.

Conclusion

Preoperative three-dimensional imaging and systemic indocyanine green injection enabled us to successfully conduct challenging segmentectomy in a patient with an anomalous bronchus.

Rotationally Resolved Excitation Spectra Measured by Slow Electron Detachment from Si2. J Phys Chem Lett 2020;11:5199-5203. [PMID: 32519868 DOI: 10.1021/acs.jpclett.0c01057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Laser-induced delayed electron detachment from Si₂^- stored in an electrostatic ion storage ring was observed on the 10 microsecond time scale. The excitation spectra for photon energies near threshold show well-resolved multipeak structures, which are attributed to rovibronic transitions to the electronic excited state. This structure appears only in the signal measured with the delay. The occurrence of delayed detachment on such a long time scale is unusual for diatomic molecules, suggesting that both the autodetachment and fluorescence are slow.

Progressively increasing density of the solid center of a ground-glass nodule in a solitary pulmonary capillary hemangioma: A case report

Solitary pulmonary capillary hemangiomas (SPCHs) are recently recognized, rare benign lesions that form solitary nodules owing to capillary proliferation. These lesions are usually detected incidentally as small ground-glass nodules (GGNs) on computed tomography (CT), and progressively enlarge over time. The radiological distinction from peripheral lung cancers is particularly challenging. However, to date, there have been no reports on progressive changes in the central density of SPCH on CT. An asymptomatic 49-year-old man was referred to our hospital for an abnormal shadow that was detected on chest CT during medical check-up. He was subsequently followed-up with chest CT. The nodule increased in size, and the central area became progressively denser. He underwent surgery 5 years and 10 months after the first visit owing to suspicion of lung cancer. Despite the collapse of the surgical specimen by artifacts, histopathological examination revealed a diagnosis of SPCH; collagenous fibers were found in the walls of the intralesional capillaries. The patient is presently alive without any recurrence, 6 months after the operation. In this case, the SPCH demonstrated a GGN with progressively increasing density of the central solid area on the CT. This remarkable feature made the preoperative distinction from lung cancer particularly difficult.

[The Current Status and Future of Robot-assisted Thoracic Surgery]

In the pursuit of minimally invasive surgery, there is no objection to the replacement of conventional open surgery with robotic surgery in highly difficult cases of pulmonary and mediastinal tumors. However, compared to video-assisted thoracoscopic surgery, the benefits of performing robotic surgery in standard lung cancer cases are few. A surgeon with master robotic skills, in addition to excellent 3-dimensional( 3D) camera control, can effectively use a retraction arm instead of increasing the number of the port. We think that such a surgeon can have an extremely high success rate. We started performing robotic surgery in September 2018 and have had more than 70 cases since then. We developed a manual to promote patient safety and common understanding between the operator and surgical assistants. In this manuscript, we introduce our current robotic surgery technique for lung cancer. The current status, problems, and the future of robotic thoracic surgery are also described.

Adult worm exclusion and histological data of dogs repeatedly infected with the cestode Echinococcus multilocularis

The data presented in this article are related to a previously published research article titled "The timing of worm exclusion in dogs repeatedly infected with the cestode Echinococcus multilocularis" (2016) [1]. This data describe a comparison of worm exclusion in the early stage of infection (1 day and 6 days post-infection) between dogs infected for the first time (control group) and dogs repeatedly infected with the parasite 4 times (repeated infection groups). We observed that 6 days post reinfection, the number of adult worms in repeated-infection groups decreased by 88.7% compared with the control group. Histological analysis comparison of the small intestinal mucosa from healthy, first infected, and repeatedly infected dogs are also reported. We observed no clear pathological abnormality, except the shortening of microvillus in reinfected dogs. However, eosinophil accumulation and eosinophilic ulcers were observed in some reinfected dogs. This data could be useful as preliminary data to develop a final host vaccine for this parasite.

Arteritis and Plexiform Lesion in Intralobar Pulmonary Sequestration: The First Case With Such Two Distinct Complex Lesions Associated With Local Pulmonary Hypertension

In intralobar pulmonary sequestrations, vascular changes similar to those in pulmonary hypertension (PH) are generally observed, such as intimal proliferation and plexiform lesions. However, to our knowledge, a sequestrated lung manifesting vascular changes with both arteritis and a plexiform lesion has never been reported. A 25-year-old man was diagnosed with intralobar pulmonary sequestration. Pathologically, both arteritis and a plexiform lesion were observed in the sequestrated lung. Systemic vasculitis syndrome was clinically excluded, and the pathological findings appeared to be associated with local PH. Arteritis is an extremely rare finding; only one case of arteritis associated with local PH has been reported in intralobar sequestration. In this case, the artery near the plexiform lesion had milder inflammation and fibrosis, suggesting that the arteritis formed prior to the plexiform lesion. This is the first case of arteritis and a plexiform lesion co-occurring in intralobar pulmonary sequestration associated with local PH. This case may shed light on the formation of plexiform lesions and their association with arteritis.

Effect of CYP3A5*3 genetic variant on the metabolism of direct-acting antivirals in vitro: a different effect on asunaprevir versus daclatasvir and beclabuvir

Direct-acting antivirals, asunaprevir (ASV), daclatasvir (DCV), and beclabuvir (BCV) are known to be mainly metabolized by CYP3A enzymes; however, the differences in the detailed metabolic activities of CYP3A4 and CYP3A5 on these drugs are not well clarified. The aim of the present study was to elucidate the relative contributions of CYP3A4 and CYP3A5 to the metabolism of ASV, DCV, and BCV, as well as the effect of CYP3A5*3 genetic variant in vitro. The amount of each drug and their major metabolites were determined using LC-MS/MS. Recombinant CYP3As and CYP3A5*3-genotyped human liver microsomes (CYP3A5 expressers or non-expressers) were used for the determination of their metabolic activities. The contribution of CYP3A5 to ASV metabolism was considerable compared to that of CYP3A4. Consistently, ASV metabolic activity in CYP3A5 expressers was higher than those in CYP3A5 non-expresser. Moreover, CYP3A5 expression level was significantly correlated with ASV metabolism. In contrast, these observations were not found in DCV and BCV metabolism. To our knowledge, this is the first study to directly demonstrate the effect of CYP3A5*3 genetic variants on the metabolism of ASV. The findings of the present study may provide basic information on ASV, DCV, and BCV metabolisms.

Regulatory aspects of quality and safety for live recombinant viral vaccines against infectious diseases in Japan

Recombinant viral vaccines expressing antigens of pathogenic microbes (e.g., HIV, Ebola virus, and malaria) have been designed to overcome the insufficient immune responses induced by the conventional vaccines. Our knowledge of and clinical experience with the new recombinant viral vaccines are insufficient, and a clear regulatory pathway is needed for the further development and evaluation of recombinant viral vaccines. In 2018, the research group supported by the Ministry of Health, Labour and Welfare, Japan (MHLW) published a concept paper to address the development of recombinant viral vaccines against infectious diseases. Herein we summarize the concept paper-which explains the Japanese regulatory concerns about recombinant viral vaccines-and provide a focus of discussion about the development of recombinant viral vaccines.

Eucoleus garfiai (Gállego et Mas-Coma, 1975) (Nematoda: Capillariidae) infection in wild boars (Sus scrofa leucomystax) from the Amakusa Islands, Japan

We examined lingual tissues of Japanese wild boars (Sus scrofa leucomystax) captured in the Amakusa Islands off the coast of Kumamoto Prefecture. One hundred and forty wild boars were caught in 11 different locations in Kamishima (n = 36) and Shimoshima (n = 104) in the Amakusa Islands, Japan between January 2016 and April 2018. Lingual tissues were subjected to histological examinations, where helminths and their eggs were observed in the epithelium of 51 samples (36.4%). No significant differences in prevalence were observed according to maturity, sex or capture location. Lingual tissues positive for helminth infection were randomly selected and intact male and female worms were collected for morphological measurements. Based on the host species, site of infection, and morphological details, we identified the parasite as Eucoleus garfiai (Gállego et Mas-Coma, 1975) Moravec, 1982 (syn. Capillaria garfiai). This is the first report from outside Europe of E. garfiai infection in wild boars. Phylogenetic analysis of the parasite using the 18S ribosomal RNA gene sequence confirmed that the parasite grouped with other Eucoleus species, providing additional nucleotide sequence for this genus. Since wild boar populations are widely distributed in Japan, continuing surveys on the epidemiology of the parasite and identifying possible intermediate host candidates are crucial for elucidating the transmission route of the parasite.

Cerebral Embolism Caused by Thrombus in the Pulmonary Vein Stump after Left Lower Lobectomy: A Case Report and Literature Review

Cerebral embolism after left upper lobectomy caused by a thrombus in the pulmonary vein stump (PVS) is a serious complication. However, it is unclear if cerebral embolism can develop after other types of lobectomy. We present a case of a 68-year-old man with cerebral embolism after left lower lobectomy with a longer PVS than normal. There were no clinically suspected sources for the thrombus except for the PVS. This thrombus seemed to have formed in the PVS. The endovascularly removed thrombus contained scattered nuclear debris around neutrophils, suggesting a physiological response caused by tissue injury.

Effect of patient position during virtual-assisted lung mapping

Background

Virtual-assisted lung mapping (VAL-MAP) is a preoperative multi-spot bronchoscopic dye-marking technique. Marking failure reportedly occurs in approximately 10% of marks. The aim of the present study was to investigate whether the patient position during dye injection in VAL-MAP affected the quality of markings.

Methods

This study was a retrospective review of patients with barely palpable pulmonary nodules who underwent VAL-MAP at a single institution between December 2016 and September 2017. Easily visible markings without bulla formation were defined as "appropriate", while other markings were defined as "inappropriate". Patients were divided in accordance with the position during dye injection into the supine position group (n=6) and the lateral position group (n=8). The two groups were compared regarding the appropriate markings rate. The Fisher exact test and logistic regression model were used for statistical analyses.

Results

Fourteen patients with 17 nodules underwent VAL-MAP with a total of 48 markings (3.4±0.9 markings per patient). Of these, 21 markings were performed in supine position, whereas 27 were performed in lateral position. There were no significant differences between the two groups in lesion size, depth, and characteristics. Almost all of the performed procedures were thoracoscopic wedge resections (94%), while one procedure was thoracoscopic left upper division segmentectomy. The appropriate markings rate was significantly greater in the lateral position group than in the supine position group (88% vs. 57%, P=0.02). Among the markings located in dorsal and ventral lung segments, the appropriate markings rate in the lateral position group tended to be greater than that in the supine position group (89% vs. 59%, P=0.06). Multivariate logistic regression analysis revealed that the lateral position was independently associated with appropriate markings (P=0.014).

Conclusions

The lateral position may enable the creation of better quality markings in VAL-MAP.

Radiative cooling of cationic carbon clusters, CN+, N = 8, 10, 13-16

The radiative cooling of highly excited carbon cluster cations of sizes N = 8, 10, 13-16 has been studied in an electrostatic storage ring. The cooling rate constants vary with cluster size from a maximum at N = 8 of 2.6 × 10⁴ s^-1 and a minimum at N = 13 of 4.4 × 10³ s^-1. The high rates indicate that photon emission takes place from electronically excited ions, providing a strong stabilizing cooling of the molecules.

Influence of Smoking and Histologic Subtype on Developing Extrathymic Malignancy in Thymoma Patients

BACKGROUND

Patients with thymomas are at high risk of developing extrathymic malignancies. We investigated the impact of extrathymic malignancies on the prognosis of patients with thymoma who underwent surgery and the risk factors for postoperative extrathymic malignancies.

METHODS

A multicenter retrospective review of 252 patients who underwent surgical resection of thymomas from January 1977 to March 2016 was conducted. The exclusion criteria were recurrent thymoma, rare types of thymoma, and missing data. The overall number and incidence of extrathymic malignancies were calculated. Potential predictors of extrathymic malignancies were also evaluated.

RESULTS

Two hundred twenty-eight patients were analyzed. Fifty-five extrathymic malignancies were observed (23 postoperative, 8 synchronous, and 24 preoperative). Among the overall cohort, the incidence of extrathymic malignancies significantly increased the patients' risk of death (hazard ratio [HR], 4.02; 95% confidence interval [CI], 1.72 to 9.40; p < 0.01). Among patients aged less than 70 years, the incidence of extrathymic malignancies was an independent risk factor for death. The incidence of postoperative extrathymic malignancies was significantly higher in patients with indolent forms of thymoma (type A/AB/B1) than aggressive forms (type B2/B3) (p = 0.02). In the multivariate analysis, indolent forms of thymoma (type A/AB/B1) (HR, 4.03; 95% CI, 1.12 to 14.6, p = 0.03) and a history of ever having smoked (HR, 5.29; 95% CI, 1.30 to 21.6; p = 0.02) were significant risk factors for the cumulative incidence of postoperative extrathymic malignancies.

CONCLUSIONS

Extrathymic malignancies increased the risk of death in patients with thymomas. Indolent forms of thymoma and a history of ever having smoked were risk factors for postoperative extrathymic malignancies.

Minor contribution of CYP3A5 to the metabolism of hepatitis C protease inhibitor paritaprevir in vitro

Paritaprevir (PTV) is a non-structural protein 3/4A protease inhibitor developed for the treatment of hepatitis C disease as a fixed dose combination of ombitasvir (OBV) and ritonavir (RTV) with or without dasabuvir. The aim of this study was to evaluate the effects of cytochrome P450 (CYP) 3A5 on in vitro PTV metabolism using human recombinant CYP3A4, CYP3A5 (rCYP3A4, rCYP3A5) and human liver microsomes (HLMs) genotyped as either CYP3A5*1/*1, CYP3A5*1/*3 or CYP3A5*3/*3. The intrinsic clearance (CL_int, V_max/K_m) for the production of a metabolite from PTV in rCYP3A4 was 1.5 times higher than that in rCYP3A5. The PTV metabolism in CYP3A5*1/*1 and CYP3A5*1/*3 HLMs expressing CYP3A5 was comparable to that in CYP3A5*3/*3 HLMs, which lack CYP3A5. CYP3A4 expression level was significantly correlated with PTV disappearance rate and metabolite formation. In contrast, there was no such correlation found for CYP3A5 expression level. This study represents that the major CYP isoform involved in PTV metabolism is CYP3A4, with CYP3A5 having a minor role in PTV metabolism. The findings of the present study may provide foundational information on PTV metabolism, and may further support dosing practices in HCV-infected patients prescribed PTV-based therapy.

Extended thoracotomy with subcostal incision for giant solitary fibrous tumor of the diaphragm

Solitary fibrous tumors of the pleura (SFTPs) are rare spindle cell neoplasms. The standard treatment is complete resection, but this may be challenging if the tumor is extremely large and originates from the diaphragm. We experienced a case of a giant solitary fibrous tumor originating from the diaphragm. A 74-year-old man presented with an asymptomatic giant mass on the right diaphragm suspicious of a solitary fibrous tumor. We performed a subcostal incision following posterolateral thoracotomy for complete resection. This surgical approach provided a better field around the diaphragm and facilitated radical and safe complete en bloc resection. The pathological diagnosis was a malignant solitary fibrous tumor. The patient survived for 1 year postoperatively without recurrence. We conclude that extended thoracotomy combined with a subcostal incision is a useful approach for surgical removal of giant tumors of the diaphragm.