Liposomal Amphotericin B Formulation Displaying Lipid-Modified Chitin-Binding Domains with Enhanced Antifungal Activity.

Fungal infections affect more than one billion people worldwide and cause more than one million deaths per year. Amphotericin B (AmB), a polyene antifungal drug, has been used as the gold standard for many years because of its broad antifungal spectrum, high activity, and low tendency of drug resistance. However, the side effects of AmB, such as nephrotoxicity and hepatotoxicity, have hampered its widespread use, leading to the development of a liposome-type AmB formulation, AmBisome. Herein, we report a simple but highly effective strategy to enhance the antifungal activity of AmBisome with a lipid-modified protein. The chitin-binding domain (LysM) of the antifungal chitinase, Pteris ryukyuensis chitinase A (PrChiA), a small 5.3 kDa protein that binds to fungal cell wall chitin, was engineered to have a glutamine-containing peptide tag at the C-terminus for the microbial transglutaminase (MTG)-catalyzed crosslinking reaction (LysM-Q). LysM-Q was site-specifically modified with a lysine-containing lipid peptide substrate of MTG with a palmitoyl moiety (Pal-K). The resulting palmitoylated LysM (LysM-Pal) exhibited negligible cytotoxicity to mammalian cells and can be easily anchored to yield LysM-presenting AmBisome (LysM-AmBisome). LysM-AmBisome exhibited a dramatic enhancement of antifungal activity toward Trichoderma viride and Cryptococcus neoformans, demonstrating the marked impact of displaying a cell-wall binder protein on the targeting ability of antifungal liposomal formulations. Our simple strategy with enzymatic protein lipidation provides a potent approach to upgrade other types of lipid-based drug formulations.

Preparation of amphotericin B-loaded hybrid liposomes and the integration of chitin-binding proteins for enhanced antifungal activity.

Amphotericin B (AMB) is a gold standard antifungal drug because of its broad-spectrum activity toward pathogenic yeasts and molds. Because of its low solubility in water and toxicity toward humans, several lipid-based formulations that either increase the aqueous solubility or decrease the side effects have been employed in practical use. In our previous research, we found that the combination of AMB with an artificial palmitoylated chitin-binding domain from Pteris ryukyuensis chitinase (LysM-Pal) resulted in synergistic antifungal action against Trichoderma viride. Herein, we prepared hybrid liposomal formulations by combining a commercially available AMB formulation and liposomes with different surface charges to explore key factors in the antifungal activity. The characterization of AMB-loaded liposomal formulations (AMB-LFs), including particle size distribution and zeta potential, showed that anionic and neutral AMB-LFs could stably encapsulate AMB. The combination of either anionic or neutral AMB-LFs with unmodified LysM decreased the minimum inhibitory concentration of AMB. The combination of neutral AMB-LF with LysM-Pal resulted in a further decrease in the MIC, up to 15-fold compared with that of the neutral AMB-LF alone. Our results demonstrate the potential utility of lipid-based liposomal formulations of AMB combined with lipid-modified proteinaceous binders to tackle fungal infections.

Enhancement of the Antifungal Activity of Chitinase by Palmitoylation and the Synergy of Palmitoylated Chitinase with Amphotericin B.

Combinations of antifungal drugs can have synergistic antifungal activity, achieving high therapeutic efficacy while minimizing the side effects. Amphotericin B (AMB) has been used as a standard antifungal drug for fungal infections; however, because of its high toxicity, new strategies to minimize the required dose are desirable. Chitinases have recently received attention as alternative safe antifungal agents. Herein, we report the combination of palmitoylated chitinase domains with AMB to enhance the antifungal activity. The chitin-binding domain (LysM) from Pteris ryukyuensis chitinase was site-specifically palmitoylated by conjugation reaction catalyzed by microbial transglutaminase. The palmitoylated LysM (LysM-Pal) exhibited strong antifungal activity against Trichoderma viride, inhibiting the growth completely at a concentration of 2 µM. This antifungal effect of LysM-Pal was mainly due to the effect of anchoring of palmitic acid motif to the plasma membrane of fungi. A combination of AMB with LysM-Pal resulted in synergistic enhancement of the antifungal activity. Intriguingly, LysM-Pal exhibited higher level of antifungal activity enhancement than palmitoylated catalytic domain (CatD) and fusion of LysM and CatD. Addition of 0.5 µM LysM-Pal to AMB reduced the minimal inhibition concentration of AMB to 0.31 µM (2.5 µM without LysM-Pal). The possible mechanism of the synergistic effect of AMB and LysM-Pal is destabilization of the plasma membrane by anchoring of palmitic acid and ergosterol extraction by AMB and destabilization of the chitin layer by LysM binding. The combination of LysM-Pal with AMB can drastically reduce the dose of AMB and may be a useful strategy to treat fungal infections.

[Ascending Aorta and Aortic Valve Replacement in Unicuspid Aortic Valve:Report of a Case].

A 53-year-old male was admitted to our hospital due to severe aortic stenosis and mild aortic regurgitation. The patient had no heart failure symptoms, but aortic stenosis progressed year by year. Aortic valve dysfunction caused by unicuspid aortic valve (UAV). Intraoperative transesophageal echocardiography contributed to diagnose UAV, three-dimentional echocardiographic imaging can be used for better evaluation. Intraoperative finding showed one open commissure between the left- and non-coronary cusp position, and this shape of valve is classified unicommissural unicuspid aortic valve. Also ascending aortic dilatation was found in this case, we replaced both ascending aorta and aortic valve. The postoperative course was uneventful. We report a very rare case of unicuspid aortic valve including aortic dilatation.

Impact of valvuloarterial impedance on left ventricular reverse remodeling after aortic valve neocuspidization.

BACKGROUND: Aortic valve neocuspidization (AVNeo) has emerged as a promising aortic valve procedure, and is expected to have a larger effective orifice area (EOA) than commercially available bioprostheses. It is, however, unclear which indices could facilitate left ventricular (LV) reverse remodeling after AVNeo. The aim of this study is to verify the impact of global left ventricular afterload on the LV reverse remodeling following AVNeo. METHODS: Data-available consecutive 38 patients (median age, 77; interquartile range, 72.8-82.0) undergoing AVNeo for severe aortic stenosis were enrolled in this study. Preoperative and the last follow-up echocardiographic data were retrospectively analyzed including the valvuloarterial impedance (Zva), a marker of global LV afterload. Reduction in LV geometry index (LVGI) and relative wall thickness (RWT) were used as an indicator for LV reverse remodeling. RESULTS: The Zva reduced in 24 patients (63.2%) during the follow-up period (median, 12 months). Reduction in Zva significantly correlated to improvement of LV geometry (LVGI (r = 0.400, p = 0.013) and RWT (r = 0.627, p < 0.001)), whereas increase in EOA index did not significantly correlate to LVGI (r = 0.009, p = 0.957), or RWT (r = 0.105, p = 0.529)). The reduction in Zva was the multivariate predictor of LV reverse remodeling. CONCLUSIONS: Low global LV afterload led to significant LV reverse remodeling even after AVNeo, which could achieve better valve performance than the conventional bioprostheses.

Clinical Results 5 Years after Great Saphenous Vein Stripping.

Background: As a standard treatment for the varicose vein of the great saphenous vein (GSV) type, endovenous ablation (EVA) is the main approach. However, as a background to this, in Europe and the United States, neovascularization (Neo) following high ligation (HL) of the saphenofemoral junction (SFJ) at the time of GSV stripping has been emphasized as one of the reasons for the high rate of recurrence. However, in Japan, almost no similar mid- or long-term results of GSV stripping have been reported. Patients and Methods: From September 2011 to March 2014 when EVA was not my surgical option, 413 consecutive legs of patients underwent GSV stripping by myself using the same procedure. The patients were contacted by phone 5 years later, and recurrent varices after surgery (REVAS) and reoperation (REDO) were investigated. A total of 270 legs of the 391 living cases (69%) underwent venous ultrasonography (VUS). HL of the SFJ was performed via central flash ligation with towing and pulling out of the peripheral side branches containing the accessory saphenous veins. In principle, GSV stripping was performed using the invagination method in the range of the entire reflux region from the HL cut section to the confluent section of the side branch causing branch varicose veins. The range of stripping was to the upper thigh in 3 legs, to the middle thigh in 3 legs, to the lower thigh in 7 legs, to the knee in 46 legs, to the upper calve in 83 legs, to the middle calve in 52 legs, and over the full length in 76 legs. Stab avulsion was performed as much as possible for the side-branch varices. On VUS, the SFJ's stump of GSV, the presence of side-branch remnants and their reflux, the presence or absence of Neo, and the recurrent lesions in other sites were evaluated. REVAS were classified as follows: Level 1, symptomatic recurrent lesion for which surgery is indicated; Level 2, asymptomatic recurrent lesion possibly requiring future surgery; and Level 3, asymptomatic recurrent lesion that is unlikely to require future surgery. Results: Of the 391 legs of patients who could be contacted, REDO was performed in 23 (6%), including 15 limbs, immediately after this investigation, and symptomatic REVAS were observed in 29 (7%). In 270 legs examined by VUS, REVAS were diagnosed as follows: 29 legs with Level 1 lesion, 40 legs with Level 2 lesion, and 27 legs with Level 3 lesion. Level 1 REVAS that occurred at the SFJ were observed only in 3 legs (1.1%), Level 1 REVAS due to incompetent perforating veins (IPVs) were observed in 14 legs (5%), and Level 1 solitary tributary varices were observed in 9 legs (3%). Conclusion: In this study, REVAS at the SFJ were significantly less than those in the past reports. It has been shown that REVAS due to IPVs or solitary tributary varices were more important than those at the SFJ. (This is a translation of Jpn J Phlebol 2019; 30(3): 259-265.).

[Lung Cancer Diagnosed as Primary Site Two Years after the Resection of the Thoracic Wall Cancer of Unknown Primary].

A 73-year-old man was referred to our department because of the left chest wall tumor. Computed tomography(CT) showed a chest wall tumor. The chest wall resection was carried out and the tumor was diagnosed as metastatic squamous cell carcinoma of unknown primary. The elevated serum level of carcinoembryonic antigen (CEA) was normalized after the surgery. Two years after the resection, the serum level of CEA elevated again and CT showed the pulmonary tumor 20 mm in diameter in the left upper lobe adjoining to the mediastinal pleura. The partial resection of the left upper lobe with mediastinal pleura was carried out. Pathological examination revealed this tumor to be the primary site of the previously resected chest wall tumor.

[Ethanol Instillation for Mediastinal Cyst].

Mediastinal cyst rarely becomes symptomatic due to compression of adjacent organs. In such case, treatment has to be considered. Either surgical extirpation or percutaneous decompression is the treatment of choice. A 53 years old woman who had been diagnosed with intractable epilepsy, mental retardation and Chilaiditi syndrome was admitted to our hospital because of dyspnea and difficulty in conversation. Chest computed tomography (CT) revealed a mediastinal cystic lesion which expanded to the right chest cavity and occupied most of the right chest cavity. That cyst was treated by percutaneous aspiration and ethanol instillation successfully. Ethanol instillation for the symptomatic mediastinal cyst is the treatment of choice in case the surgery is not feasible.

Double Inferior Vena Cava with Azygos Continuation and Retroaortic Left Renal Vein Associated with Juxtarenal Abdominal Aortic Aneurysm Surgery.

The combination of a double inferior vena cava (IVC), a retroaortic left renal vein, and azygos continuation of the IVC is extremely rare. Here we report the case of a 74-year-old man with this complex venous anomaly associated with a juxtarenal abdominal aortic aneurysm (AAA), who underwent a successful graft implantation with left renal artery reconstruction without injuring the retroaortic venous system. The venous anomaly was diagnosed using preoperative contrast-enhanced computed tomography (CT). Thus, contrast-enhanced CT can provide sufficient information on AAA and anomalous venous anatomy to avoid fatal complications during AAA surgery.

[Effectiveness of perioperative administration of eltrombopag in a patient with idiopathic thrombocytopenic purpura undergoing cardiovascular surgery].

We report a case of chronic aortic dissection and angina pectoris with idiopathic thrombocytopenic purpura treated perioperatively with eltrombopag. A 72-year-old man was admitted to our hospital because of significant enlargement of an ulcer-like projection in the thoracic aorta revealed by chest computed tomography after acute aortic dissection. Laboratory data showed thrombocytopenia with idiopathic thrombocytopenic purpura. Eltrombopag was administered 12.5 mg daily and increased by 12.5 mg every 2 weeks until 37.5 mg/day to control idiopathic thrombocytopenic purpura(ITP). After 7 weeks' eltrombopag therapy, thrombocyte increased, and the patient underwent total arch replacement. Nine months later, coronary angiography revealed progression of coronary artery stenosis at the left main trunk. The patient underwent off-pump coronary artery bypass grafting 10 days after initiation of eltrombopag therapy. His postoperative course was uneventful. Eltrombopag was suggested to be effective in perioperative management in a patient with idiopathic thrombocytopenic purpura undergoing cardiovascular surgery.

Subfascial endoscopic perforator surgery for posterolateral perforators performed in the prone position.

OBJECTIVES: Subfascial endoscopic perforator surgery (SEPS) is usually performed for posteromedial perforators in the supine position, but subfascial endoscopic perforator surgery for posterolateral perforators in the prone position has not been reported. METHODS: A 51-year-old male suffered from a venous stasis ulcer around his lateral malleolus because of reflux in the small saphenous vein and incompetent perforating veins around the ulcer. RESULTS: Stripping of the small saphenous vein and subfascial endoscopic perforator surgery utilizing screw-type ports was successfully conducted in the prone position. CONCLUSIONS: The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space.

[Successful resection of lung cancer with idiopathic pulmonary fibrosis treated by pirfenidone during perioperative period].

We report a case of lung cancer treated with pirfenidone as preoperative therapy before subsequent successful surgical resection. A 76-year-old man was admitted to our hospital because of abnormal shadows and diffuse reticular shadow in bilateral lung on chest computed tomography(CT). CT-guided percutaneous lung biopsy confirmed suquamous cell carcinoma for both lung. Pulmonary reticular shadow was diagnosed as idiopathic pulmonary fibrosis (IPF) clinically and the pirfenidone was administered 600 mg daily and increased by 600 mg for every week until 1,800 mg/day to control IPF. After 3 weeks pirfenidone therapy, Krebs von den Lungen( KL)-6, pulmonary surfactant( SP)-D and lactate dehydrogenase (LDH) decreased, and the patient underwent wedge resection. His postoperative course was uneventful.

[Lung cancer occurring in a left upper division which is mirror imaged to a right upper lobe].

A 55-year-old man was admitted to our hospital because of an abnormal shadow in the left upper division on chest computed tomography(CT). Virtual bronchoscopy revealed a displaced anomalous bronchus. Thin sliced CT revealed complete lobulation between the upper division and the lingula. Three dimensional (3D)-CT revealed abnormal distribution of the left pulmonary artery which descended without passing over the left main bronchus. The left upper division was evaluated to be mirror imaged to a right upper lobe. Video assisted thoracoscopic left upper divisionectomy was performed. The tumor was diagnosed as adenocarcinoma( pT1aN0M0:p-stage I A).

Subfascial endoscopic perforator surgery using screw-type ports is a very useful component of a comprehensive treatment program for chronic venous insufficiency.

BACKGROUND: Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009. PATIENTS AND METHODS: Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery. RESULTS: All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS. CONCLUSION: SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.

Bronchopulmonary foregut malformation.

Bronchopulmonary foregut malformation (BPFM) is a rare anomaly of accessory pulmonary tissue that usually arises from esophagus or stomach. We present a case of extralobar pulmonary sequestration (ELS) connecting with the esophagus by a cyst, the inner wall of which is lined with squamous epithelium or respiratory epithelium. BPFM is sometimes used to group a number of ventral anomalies of accessory pulmonary tissue. The term currently refers specifically to those lesions composed of sequestrations that retain communication with the gastrointestinal tract. Usually the communication is a well-formed muscular tube lined with stratified squamous or columnar epithelium. The presence of both epithelia in a communication that is a component of the BPFM suggests embryogenesis. We describe an adult with BPFM composed of ELS and a connecting stalk to the esophagus by a foregut cyst that contains both squamous epithelium and respiratory epithelium.

[Cavernous hemangioma of the superior mediastinum; report of a case].

A 44-year-old female was admitted with an abnormal left mediastinal shadow on chest roentgenography. Computed tomography (CT) revealed a mass lesion in the left superior mediastinum, which was not enhanced with contrast medium. Magnetic resonance imaging demonstrated equal signal intensity to that of the muscle on T1 weighted images, and higher signal intensity on T2 weighted images. As a cystic mediastinal tumor was suspected preoperatively, thoracoscopic excision was performed. The tumor was diagnosed as a cavernous hemangioma by pathology. A preoperative diagnosis is difficult because of a variable feature of image study. When the diagnosis of the cystic tumor of mediastinum is made, the diagnosis of mediastinal hemangioma should be kept in mind.

Removal of prostaglandin E2 and increased intraoperative blood pressure during modified ultrafiltration in pediatric cardiac surgery.

OBJECTIVE: We investigated the relationship between serum prostaglandin E(2) and intraoperative blood pressure in pediatric cardiac surgery with modified ultrafiltration. METHODS: In 35 consecutive patients (31.6 +/- 26.8 months, 0.4-111 months, 10.9 +/- 5.5 kg, 2.9-23.8 kg) who underwent cardiac surgery with modified ultrafiltration, we measured intraoperative serum prostaglandin E(2) changes and effluent prostaglandin E(2), assessed the relationship between serum prostaglandin E(2) and intraoperative hemodynamic parameters, and performed subset analyses to compare patients with low (<10 kg, n = 18) and high (>10 kg, n = 10) weights. RESULTS: During cardiopulmonary bypass, systolic blood pressure decreased from 80.8 +/- 15.2 to 60.5 +/- 11.3 mm Hg (P = .00000002979) and serum prostaglandin E(2) increased from 16.6 +/- 8.7 to 58.8 +/- 53.3 pg/mL (P = .002). During modified ultrafiltration, although central venous pressure and catecholamine dosage transited at the same levels, systolic blood pressure increased from 60.5 +/- 11.3 to 83.4 +/- 14.1 mm Hg (P = .00000002979) and serum prostaglandin E(2) decreased from 58.8 +/- 53.3 to 21.1 +/- 11.6 pg/mL (P = .001), with negative correlation between serum prostaglandin E(2) and systolic blood pressure (R = -0.392, P = .0000277723) and 15,700 +/- 10,700 pg (1790 +/- 2230 pg/kg) prostaglandin E(2) removed during modified ultrafiltration. Decrease in serum prostaglandin E(2) was significantly higher in low-weight patients (51.8 +/- 58.4 pg/mL) than in high-weight patients (15.7 +/- 30.1 pg/mL). CONCLUSION: Removal of prostaglandin E(2) is one reason for increased blood pressure during modified ultrafiltration, with the effect more marked in low-weight patients.

Intravalvular implantation technique for a modified Bentall's procedure in aortitis syndrome.

Surgical treatments of aortic root involvement in aortitis syndrome are frequently complicated by valve detachment and pseudoaneurysmal formation during active inflammation. A 40-year-old woman with aortitis syndrome complicating the ascending aortic aneurysm, severe aortic regurgitation (AR), and left coronary ostial stenosis was successfully treated by aortic root replacement and concomitant coronary artery bypass grafting (CABG) during acute inflammation. We devised an intravalvular implantation between the fragile aortic annulus and Teflon felt to a modified Bentall's procedure, which prevented anastomotic leakage and pseudoaneurysmal formation in the late period.

Infected papillary fibroelastoma attached to the atrial septum.

A 61-year-old woman had intermittent fever of 2 months' duration following a dental extraction. On admission, her body temperature was 39.2 degrees C. A mid-systolic murmur was heard at the apex on ausculation. A 2-dimensional echocardiogram revealed a mobile, heavy stick-like mass with vegetation (5.0 x 1.5 cm) attached to the left atrial septum. Multiple blood cultures grew Streptococcus constellatus. On diagnosis of an infected left atrial myxoma, antibiotics were administered daily and 4 weeks later, the left atrial tumor was resected. The tumor was 5.3cm long, 1.5cm in diameter at the inter-atrial wall and had vegetation on the free edge. On microscopic examination, colonies of Gram-positive cocci were found in the thrombus, on the papillary fibroelastoma. After treatment with antibiotics for a further 4 weeks, the patient was discharged. This is the first report of infected papillary fibroelastoma.