Epidemiological and clinical characteristics of community-acquired severe sepsis and septic shock: a prospective observational study in 12 university hospitals in Korea

A prospective multicenter observational study was performed to investigate the epidemiology and outcomes of community-acquired severe sepsis and septic shock. Subjects included 1,192 adult patients admitted to the 22 participating intensive care units (ICUs) of 12 university hospitals in the Korean Sepsis Registry System from April, 2005 through February, 2009. Male accounted for 656 (55%) patients. Mean age was 65.0 ± 14.2 yr. Septic shock developed in 740 (62.1%) patients. Bacteremia was present in 422 (35.4%) patients. The 28-day and in-hospital mortality rates were 23.0% and 28.0%, respectively. Men were more likely to have comorbid illnesses and acute organ dysfunctions, and had higher mortality and clinical severity compared to women. While respiratory sources of sepsis were common in men, urinary sources were predominant in women. In the multivariate logistic regression analysis, cancer (odds ratio 1.89; 95% confidence interval 1.13-3.17), urinary tract infection (0.25; 0.13-0.46), APACHE II score (1.05; 1.02-1.09), SOFA score on day 1 (1.13; 1.06-1.21) and metabolic dysfunction (2.24, 1.45-3.45) were independent clinical factors for gender-related in-hospital mortality. This study provided epidemiological and clinical characteristics of community-acquired severe sepsis and septic shock in ICUs in Korea, and demonstrated the impact of clinical factors on gender difference in mortality.

Ginsenoside Rs(3), a genuine dammarane-glycoside from Korean red ginseng

A genuine dammarane-glycoside, named as ginsenoside Rs(3), was isolated from the MeOH extracts of Korean red ginseng (Panax ginseng C.A. Meyer) through repeated silica gel column chromatographies and its chemical structure was determined as (20S)-protopanaxadiol 3-O-[6''-O-acetyl-beta-D-glucopyranosyl (1-->2)-beta-D-glucopyranoside on the basis of several spectral and physical evidences including HMBC and FAB-MS.

A decision tree-based approach for identifying urban-rural differences in metabolic syndrome risk factors in the adult Korean population

AIM

The purpose of this study was to explore the difference in the pattern of metabolic syndrome (MetS) in urban and rural populations in Korea using data mining techniques.

SUBJECTS AND METHODS

In total, 1013 adults >30 yr of age from urban (184 males and 313 females) and rural districts (211 males and 305 females) were recruited from Gyeongsangnam-do, Korea. Modified National Cholesterol Education Program Adult Treatment Panel III criteria were used to identify individuals with MetS. We applied a decision tree analysis to elucidate the differences in the clustering of MetS components between the urban and rural populations.

RESULTS

The prevalence of MetS was 33.2% and 35.2% in urban and rural districts, respectively (p=0.598). The decision-tree approach revealed that the combination of high serum triglycerides (TG) + high systolic blood pressure (SBP), high TG + low HDL cholesterol, and high waist circumference (WC) + high SBP + high fasting plasma glucose (FPG) were strong predictors of MetS in the urban population, whereas the combination of TG + SBP + WC and SBP + WC + FPG showed high positive predictive value for the presence of MetS in the rural population.

CONCLUSIONS

Although no significant difference was found for the prevalence of MetS between the two populations, the differences in the clustering pattern of MetS components in urban and rural districts in Korea were identified by decision tree analysis. Our findings may serve as a basis to design necessary population-based intervention programs for prevention and progression of MetS and its complications in Korea.

Differences in the risk factors for surgical site infection between total hip arthroplasty and total knee arthroplasty in the Korean Nosocomial Infections Surveillance System (KONIS)

OBJECTIVE

To compare the characteristics and risk factors for surgical site infections (SSIs) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a nationwide survey, using shared case detection and recording systems.

DESIGN

Retrospective cohort study.

SETTING

Twenty-six hospitals participating in the Korean Nosocomial Infections Surveillance System (KONIS).

PATIENTS

From 2006 to 2009, all patients undergoing THA and TKA in KONIS were enrolled.

RESULTS

SSI occurred in 161 (2.35%) of 6,848 cases (3,422 THAs and 3,426 TKAs). Pooled mean SSI rates were 1.69% and 2.82% for THA and TKA, respectively. Of the cases we examined, 42 (26%) were superficial-incisional SSIs and 119 (74%) were "severe" SSIs; of the latter, 24 (15%) were deep-incisional SSIs and 95 (59%) were organ/space SSIs. In multivariate analysis, a duration of preoperative hospital stay of greater than 3 days was a risk factor for total SSI after both THA and TKA. Diabetes mellitus, revision surgery, prolonged duration of surgery (above the 75th percentile), and the need for surgery due to trauma were independent risk factors for total and severe SSI after THA, while male sex and an operating room without artificial ventilation were independent risk factors for total and severe SSI after TKA. A large volume of surgeries (more than 10 procedures per month) protected against total and severe SSI, but only in patients who underwent TKA.

CONCLUSIONS

Risk factors for SSI after arthroplasty differ according to the site of the arthroplasty. Therefore, clinicians should take into account the site of arthroplasty in the analysis of SSI and the development of strategies for reducing SSI.

Can immune function assay predict infection or recovery?

BACKGROUND

Recently, the ImmuKnow assay (Cylex Inc., Columbia, Md) has been reported to be a global immune monitoring tool for organ transplants recipients. We assessed whether immunKnow ATP values predicted infectious syndromes.

METHODS

We prospectively enrolled 71 kidney transplant patients between September 2008 and May 2011. lmmuKnow assay monitoring was performed at one dav before as well as 4, 8, 12, 16, 20, 24, 36, and 52 weeks after the operation. ImmuKnow assay values were compared as well as BK viral infection pre-infection(PI), at first detection of infectious syndrome (DI), 4 weeks there after (4W), 8 weeks there after (8W) and 12 weeks there after (12W) and pre-recovery (PR), recovery (R) times.

RESULTS

Serial ImmuKnow assays showed significant differences over time and BK viral infectious state (P = .026). Interestingly, PI was significantly lower than DI and PR but PR significant greater than PI, 8W and 12W. However, we did not observe an adequate or absolute cutoff value of ImmuKnow by ROC curve: 377 ng/mL ImmuKnow showed 0.471 of AUC and 57.1% and 56.2%, of sensitivity and specificity.

CONCLUSION

Longitudinal evaluation and adjustment of the value of ImmuKnow assay seemed to be a favorable modality to monitor infectious syndromes especially those involving BK virus.

Porcine feasibility and safety study of a new paclitaxel-eluting biliary stent with a Pluronic-containing membrane

BACKGROUND AND STUDY AIM

Metal stents for malignant biliary obstruction are susceptible to occlusion by tumor ingrowth or overgrowth. Therefore, we previously reported our use of a metal stent covered with a paclitaxel-incorporated membrane giving an antitumor effect to prevent occlusion from tumor ingrowth. We have also developed a new generation of paclitaxel-eluting biliary stent using a membrane containing Pluronic F-127 for effective drug delivery. The aim of this study was to investigate the safety and efficacy of drug delivery for this newly developed stent in the biliary tract.

METHODS

Metal stents were coated with paclitaxel and various concentrations of Pluronic F-127 in phosphate-buffered saline solution. Stents containing varying concentrations were placed in the bile ducts of eight pigs divided as follows: group I, 0% Pluronic + 0% paclitaxel; group II, 0% Pluronic + 10% paclitaxel; group III, 10% Pluronic + 10% paclitaxel; group IV, 20% Pluronic + 10% paclitaxel. The histology of the porcine bile duct and the amount of paclitaxel in the porcine serum were examined. The amount of paclitaxel released was also measured in vitro.

RESULTS

Histologic changes in the porcine biliary epithelium were acceptable in terms of safety, based on inflammatory cell infiltration and fibrotic reaction. No significant differences in histology were observed between the groups. In the porcine serum analysis, released paclitaxel was detected for 28 days with the 10% Pluronic concentration (group III). However, released paclitaxel was observed for only 7 days in groups II and IV. In the in vitro experiments, long-lasting release of paclitaxel was also noted from the stent with 10% Pluronic.

CONCLUSIONS

The new paclitaxel-eluting stent with 10% Pluronic F-127 is safe and provides enhanced local drug delivery.

Effectiveness of locoregional therapy before living donor liver transplantation in patients with hepatocellular carcinoma who meet the Milan criteria

BACKGROUND

Many patients are diagnosed with hepatocellular carcinoma (HCC) within the Milan criteria. In Korea, these patients are preferentially treated with locoregional therapy (LRT) instead of living donor liver transplantation. We investigated the effectiveness of LRT in liver transplant recipients who met the Milan criteria at the time of HCC diagnosis and investigated risk factors for HCC recurrence.

METHODS

We retrospectively reviewed the medical records of patients diagnosed with HCC who met the Milan criteria between 2002 and 2008.

RESULTS

We performed 101 liver transplants for HCC during the study period. Seventy-one patients (70%) underwent pretransplant LRT. The disease-free survival rates at 1, 3, and 5 years in patients who received LRT were 96.6%, 93.1%, and 93.1%, and in those who did not receive LRT, 94.2%, 83.4%, and 83.4%, respectively. There were no differences between the 2 groups. Multivariate analysis showed that a low Model for End-Stage Liver Disease (MELD) score and microvascular invasion were independent predictors of HCC recurrence after transplantation. The MELD scores and rate of microvascular invasion were not statistically different in patients with or without previous LRT.

CONCLUSION

Pretransplant LRT for patients with HCC who met the Milan criteria at the time of diagnosis did not provide a clear benefit with respect to HCC recurrence after transplantation. If patients have suitable living donors, those who meet the Milan criteria should undergo a liver transplantation as soon as possible.

Clinical factors associated with hepatitis A virus seropositivity in HIV-infected adults living in a country with an epidemiologic shift for hepatitis A virus infection

The number of HIV-infected individuals susceptible to Hepatitis A virus (HAV) infection is increasing in Korea; however, it has proven difficult to devise a vaccination policy therefore because limited seroepidemiologic data exists for them. Accordingly, anti-HAV IgG was measured in 188 HIV-infected adults between July 2008 and July 2010. The nadir CD4+ T lymphocyte counts were not different between the HAV-positive and -negative groups (197 ± 138 vs 202 ± 129, P = 0.821). The only factor independently associated with seropositive status was age under 40 yr old (OR 0.017, P < 0.001). Our findings suggest that HAV vaccination in HIV-infected adults should be targeted at persons under the age of 40 yr.

Primary versus salvage living donor liver transplantation for patients with hepatocellular carcinoma: impact of microvascular invasion on survival

OBJECTIVE

Salvage liver transplantation (LT) has been proposed for patients with a small hepatocellular carcinoma (HCC) and preserved liver function. Few reports have been issued on salvage LT in a living-donor (LD) LT setting. Therefore, we performed this study to evaluate differences in tumor invasiveness and other risk factors on survival after salvage versus primary LDLT.

METHODS

Between September 1996 and December 2008, 324 patients with HCC underwent LT. We excluded 138 patient from the analysis, leaving 186 HCC patients for analysis, including 17 (9.1%) who had undergone earlier resection, the salvage LDLT cohort. The other 169 patients underwent primary LDLT.

RESULTS

Intrahepatic metastasis, Edmonson-Steiner histologic grade, microscopic vascular invasion, and preoperative serum alpha-fetoprotein levels significantly influenced tumor recurrence. Microscopic vascular invasion, intrahepatic metastasis, Edmonson-Steiner histologic grade, and treatment by salvage LDLT were significantly associated with poor patient survival univariate analysis. However, only microscopic vascular invasion was significant on multivariate analysis. The treatment modality (primary or salvage LDLT) was not observed to affect overall or disease-free survival significantly on multivariate analysis. Disease-free survival was significantly better in the primary than in the salvage LDLT group. Furthermore, patients in the primary LDLT group tended to show better survival. However, when stratified by the presence or absence of microscopic vascular invasion, no significant group difference was found for overall or disease-free survival among those without versus with microscopic vascular invasion.

CONCLUSIONS

Five-year overall survival after primary versus salvage LDLT were similar when differences in tumor pathologic features, such as microscopic vascular invasion, were taken into account. Multivariate analysis showed that the treatment itself was not a significant prognostic factor for survival.

Anatomic similarity of the hepatic artery and portal vein according to the donor-recipient relationship

INTRODUCTION

Anatomic variants of the hepatic vasculature are common, so precise preoperative donor evaluation, including variations in the vasculature, is essential. We analyzed the anatomic similarity according to the donor-recipient relationship.

METHODS

Among the cases who underwent living donor liver transplantations from September 2008 to January 2011 we selected 104 cases with clearly defined hepatic artery and portal vein on preoperative computed tomography. They were classified according to Hiatt et al for the hepatic artery and Cheng for the portal vein. We categorized the 104 cases into three groups: parents-child (n=40), sibling (n=24) and no-relation (n=40), for analysis of the concordance of the hepatic artery and portal vein.

RESULT

Anatomic variations were observed in 25% of donors and 23.1% of recipients in the hepatic artery and 6.7% of donors and 10.6% of recipients in the portal vein. There was no significant difference in the distribution of the type of hepatic vasculature. Identical anatomic variations between donors and recipients were observed in 62.5% of the parent-child; 66.7% of the sibling and 52.5% of no-related group (P=.493) in the hepatic artery and 92.5%, 100%, and 77.5% (P=.014) in the portal vein respectively.

CONCLUSION

There was no similarity in the anatomic variations of the hepatic artery according to the donor-recipient relationship, but a similarity in portal venous anatomy according to the donor-recipient relationship.

Clinical significance of proteinuria at posttransplant year 1 in kidney transplantation

PURPOSE

Proteinuria in the nontransplant population is a progressive renal disease. We analyzed the prevalence and clinical significance of proteinuria as well as factors related to its degree at posttransplant year 1 among kidney transplant recipients.

METHODS

We measured protein in a 24-hour urine among 644 recipients from January 1996 to December 2010.

RESULTS

Among 372 male and 272 female recipients, the mean amount of urinary protein was 424.4 ± 1010 mg/d (range, 13.88-8691) including 388 (60.2%) subjects with microproteinuria and the other 256 (39.8%) with overt proteinuria. Nephrotic range proteinuria was observed in 17 (2.6%) and nonnephritic range proteinuria, in 239 (37.1%) recipients. The latter cohort was categorized into low-grade proteinuria (n = 224; 34.8%) and high-grade proteinuria (n = 15; 2.3%). Proteinuria at posttransplant 1 year highly correlated with serum creatinine values at posttransplant years 1 and 2 as well as estimated glomerular filtration rate but not creatinine clearance at postoperative year 2. A greater incidence of graft loss was observed among recipients with more severe proteinuria. Males, recipients with anti-hepatitis C virus antibody, unrelated donors, anti-thymocyte immunoglobulin at the time of reperfusion, maintenance immunosuppression with cyclosporine or without mycophenolate mofetil were strongly associated with the amount of proteinuria.

CONCLUSION

This study demonstrated the prevalence of proteinuria in kidney transplant recipient to be high. The presence as well as level of proteinuria were predictive markers for inferior allograft function.

Hormonal differences between female kidney transplant recipients and healthy women with the same gynecologic conditions

BACKGROUND

End-stage renal disease is associated with severe abnormalities in reproductive function. However, the abnormalities are reversed by successful kidney transplantation. The aim of the present study was to compare hormonal levels between recipients with successful kidney transplantations and healthy women with the same gynecologic conditions.

METHODS

The study group consisted of 31 women of reproductive age with end-stage renal disease who underwent successful kidney transplantation. The ratio of the control group, composed of healthy woman, to the study group was 3:1 matched for age and symptoms.

RESULTS

Abnormal bleeding (n = 14) and infertility were the most common gynecologic conditions in kidney transplant recipients. The levels of estrogen (E2) and follicle-stimulating hormone (FSH) in the study group were higher than in the control group, but the levels of progesterone (P4) and luteinizing hormone (LH) were lower in the study group than in the control group. There were no significant differences in prolactin and thyroid-stimulating hormone between the two groups. The incidence of infertility in patients who receive steroid was higher than those with no steroid use (P = .007).

CONCLUSIONS

Compared with healthy age- and symptom-matched women, female kidney transplant recipients have increased levels of E2 and FSH and decreased levels of P4 and LH. These differences in hormone profiles may predispose kidney transplant recipients to increased risk of gynecologic pathologies.

Comparison between thymoglobulin and ATGAM as an induction agent in adult kidney transplantation: a single-center experience

OBJECTIVE

The best antithymocyte globulin (ATG) preparation for induction suppression in kidney transplant recipients is still not clear. The aim of this study was to identify short- and long-term outcomes in kidney transplant recipients who received thymoglobulin or ATGAM as an induction agent.

METHODS

We retrospectively reviewed patients who underwent kidney transplantation from 1996 to 2010. Recipients were classified according to the ATG preparation.

RESULTS

One hundred fifty-two patients (64.4%) received thymoglobulin and 84 (35.6%) received ATGAM. The occurrence of delayed graft function in patients receiving thymoglobulin was higher than in patients receiving ATGAM (P = .005), but serum creatinine levels and acute rejection after kidney transplantation were not different between the two groups. The death-censored graft survival curve in thymoglobulin recipients was higher than in ATGAM recipients (P = .027). Bacterial infection was a predisposing factor for graft survival (P = .008).

CONCLUSION

The efficacy of thymoglobulin induction is generally better than that of ATGAM induction, and prevention of bacterial infections was just as important as the use of ATG because bacterial infection was an important risk factor for graft failure.

Association between thyroid autoimmunity and fibromyalgia

Evidence exists that autoimmune thyroiditis is present in a high percentage of fibromyalgia (FM) and associated with the presence of typical symptoms of FM. However, the role of thyroperoxidase antibody (TPO Ab) in the manifestation of FM is still unclear. The goal of this study was to investigate the prevalence of positive TPO Ab in euthyroid FM patients, and whether TPO Ab positivity is associated with the clinical manifestations in euthyroid FM patients.Thyroid assessment was done by free T4, TSH and TPO Ab. The clinical parameters including Fibromyalgia Impact questionnaire (FIQ), pain visual analogical scale (VAS) and tender point counts were evaluated in euthyroid primary FM patients, not associated with autoimmune rheumatic disease. The immunologic tests including rheumatoid factor and antinuclear antibody were measured. We compared the prevalence of positive TPO Ab between FM patients, and healthy control. We also compared clinical and laboratory parameter in FM patients according to the presence of TPO Ab.149 patients of FM, 68 healthy controls were recruited. FM patients showed higher prevalence of positive TPO Ab than healthy controls (28 out of 149 patients, 19%; 5 out of 68 healthy controls, 7%; P=0.04). There was no difference of clinical and laboratory parameters in FM patients between 2 groups subdivided by the presence of TPO Ab.In our study, euthyroid FM patients showed significantly higher prevalence of positive TPO Ab, as compared to age and sex matched healthy control. However, TPO Ab positivity was relatively low and not associated with the clinical manifestations in euthyroid FM patients. This finding support thyroid autoimmunity may influence the development of FM, but the evidence which support that FM is related to autoimmune etiology is not clear, and FM severity may not be affected by the presence of thyroid autoantibody.

Prospective nationwide surveillance of surgical site infections after gastric surgery and risk factor analysis in the Korean Nosocomial Infections Surveillance System (KONIS)

OBJECTIVE

To evaluate the risk factors for surgical site infection (SSI) after gastric surgery in patients in Korea.

DESIGN

A nationwide prospective multicenter study.

SETTING

Twenty university-affiliated hospitals in Korea.

METHODS

The Korean Nosocomial Infections Surveillance System (KONIS), a Web-based system, was developed. Patients in 20 Korean hospitals from 2007 to 2009 were prospectively monitored for SSI for up to 30 days after gastric surgery. Demographic data, hospital characteristics, and potential perioperative risk factors were collected and analyzed, using multivariate logistic regression models.

RESULTS

Of the 4,238 case patients monitored, 64.9% (2,752) were male, and mean age (± SD) was 58.8 (± 12.3) years. The SSI rates were 2.92, 6.45, and 10.87 per 100 operations for the National Nosocomial Infections Surveillance system risk index categories of 0, 1, and 2 or 3, respectively. The majority (69.4%) of the SSIs observed were organ or space SSIs. The most frequently isolated microorganisms were Staphylococcus aureus and Klebsiella pneumoniae. Male sex (odds ratio [OR], 1.67 [95% confidence interval (CI), 1.09-2.58]), increased operation time (1.20 [1.07-1.34] per 1-hour increase), reoperation (7.27 [3.68-14.38]), combined multiple procedures (1.79 [1.13-2.83]), prophylactic administration of the first antibiotic dose after skin incision (3.00 [1.09-8.23]), and prolonged duration (≥7 days) of surgical antibiotic prophylaxis (SAP; 2.70 [1.26-5.64]) were independently associated with increased risk of SSI.

CONCLUSIONS

Male sex, inappropriate SAP, and operation-related variables are independent risk factors for SSI after gastric surgery.

Effects of variation in porcine MYOD1 gene on muscle fiber characteristics, lean meat production, and meat quality traits

Three single nucleotide polymorphisms (SNPs) in the porcine MYOD1 gene were used for association analysis and haplotype construction to evaluate the effects of their substitution. Four hundred and three pigs of Yorkshire and Berkshire breeds were used. The mRNA expression levels of MYOD1 were examined. The g.489C>T and g.1264C>A SNPs were significantly associated with several muscle fiber characteristics, the loin eye area, and lightness. Particularly, animals having hetero-genotypes of both sites showed good performance both in lean meat production and meat quality traits. The results of haplotype substitution were similar to the associations of individual SNPs. Moreover, the 2 SNPs had significant effects on mRNA expression. Therefore, the g.489C>T and g.1264C>A SNPs in MYOD1 may be meaningful DNA markers that can be used for improving important porcine economic traits.

Risk factors for mortality in patients with Burkholderia cepacia complex bacteraemia

BACKGROUND

Over the last 2 decades, Burkholderia cepacia complex has emerged as a serious human pathogen, especially in critically ill patients. B. cepacia complex has been associated with increased morbidity and mortality in intensive care unit patients. However, in our literature search, we could not find studies on risk factors for mortality in patients with B. cepacia complex bacteraemia. Therefore, we investigated risk factors for mortality in B. cepacia complex bacteraemia.

METHODS

Clinical characteristics and laboratory parameters of 27 patients with 1 or more blood cultures positive for B. cepacia complex from January 2006 to October 2010 in Severance Hospital, Yonsei University College of Medicine, Korea were retrospectively analyzed. The main outcome measure was overall 28-day mortality. Appropriate initial empirical antimicrobial use was defined as administration of agent(s) to which the organism was susceptible within 24 h of obtaining blood for culture.

RESULTS

The overall 28-day mortality rate was 41% (11/27). In univariate analysis, underlying diabetes mellitus (p = 0.033), inappropriate initial empirical antimicrobial therapy (p = 0.033), and an elevated Sequential Organ Failure Assessment (SOFA) score (p = 0.002) were significantly associated with mortality. In multivariate analysis, inappropriate initial empirical antimicrobial therapy and an elevated SOFA score were independent risk factors for increased mortality (p = 0.032 and p = 0.028, respectively).

CONCLUSIONS

An elevated SOFA score and inappropriate initial empirical antimicrobial therapy were significantly associated with adverse outcome in patients with B. cepacia complex bacteraemia.

Delta neutrophil index: could it predict mortality in patients with bacteraemia?

BACKGROUND

Despite advances in therapy, sepsis still has a high mortality rate. To improve the treatment outcome, early diagnosis and treatment is essential, as reflected in many publications about biomarkers for sepsis. Recent models of automatic cell analyzers provide the delta neutrophil index (DN), which corresponds to the fraction of immature granulocytes in circulating blood. This study investigated DN as a prognostic marker in patients with bacteraemia.

METHODS

We retrospectively collected data on adult patients with bacteraemia admitted to an urban hospital between November 2009 and April 2010. The DN was measured at the onset of bacteraemia and at 24 and 72 h later. Factors associated with 28-day mortality were assessed using logistic regression.

RESULTS

A total of 102 patients were included in the analysis, and 24 patients died within 28 days. In the univariate analysis, appropriate antibiotic treatment, multidrug-resistant bacterial infection, history of intensive care unit (ICU) stay before the onset of bacteraemia, healthcare-associated infection, DN at 72 h after the onset of bacteraemia (DN-72 h), and platelet count at the onset of bacteraemia were significantly associated with survival. In multivariate analysis, DN-72 h (odds ratio (OR) 1.246, 95% confidence interval (CI) 1.030-1.508; p = 0.023), platelet count at the onset of bacteraemia (OR 0.986, 95% CI 0.977-0.995; p = 0.003), and history of ICU stay before the onset of bacteraemia (OR 4.907, 95% CI 1.045-23.051; p = 0.044) were the independent factors associated with survival.

CONCLUSION

DN at 72 h after bacteraemia may be valuable to assess the prognosis of patients with bacteraemia.

Alemtuzumab induction in deceased donor kidney transplantation

PURPOSE

Alemtuzumab (Campath-1H), a humanized monoclonal antibody directed against CD52, is a lymphocyte-depleting agent currently being evaluated as an induction agent in solid organ transplantation. This study analyzed the clinical outcomes and effects on peripheral blood lymphocyte subset counts in adult deceased donor renal transplant recipients who received an alemtuzumab-based induction protocol.

METHODS

Eleven kidney alone or simultaneous pancreas-kidney transplant recipients received 20 mg alemtuzumab on postoperative days 0 and 1, followed by calcineurin inhibitor-based maintenance immunosuppression after postoperative day 5. We collected 1-year data including recipient and donor demographic features, renal function and adverse events including endocrine impact, incidence of acute rejection episodes, infections or malignancies as well as hematologic and late immunologic parameters for correlation with patient or graft survival.

RESULTS

Mean HLA mismatch was 3.6 and 8/11 deceased donors were of the extended criteria type. Only 2 (18%) recipients displayed delayed graft function with a failure of the serum creatinine to decrease by 25% on the first day; however, their long-term outcomes were similar to other nonaffected patients. Serious adverse events were absent; there was no hyperlipidemia or new-onset diabetes. We failed to observe an acute rejection. The 3 (27%) recipients with infectious complications experienced pericardial tuberculosis, urinary tract infection, or invasive pulmonary aspergillosis. Two (18%) cases of posttransplantation lymphoproliferative disease were diagnosed in this study during the follow-up. Overall patient and graft survival rates were both 91%.

CONCLUSION

This study demonstrated that preconditioning with antibody-depletion using alemtuzumab was efficient with satisfactory patient and graft survivals at 1 year. Alemtuzumab induction was safe even for recipients of extended criteria donor renal transplantation.

Hysterectomy prevention using the uterine hollow obliterations (HYUNHO) method for placenta previa

OBJECTIVE

We have invented a method of hysterectomy prevention called the uterine hollow obliteration (HYUNHO) method to preserve the uterus and fertility after treating placenta previa or accreta.

METHODS

Eighty patients underwent cesarean section because of placenta previa between January 2003 and December 2009. All patients eligible for the study were evaluated by followup and a telephone questionnaire about fertility, menstruation recovery, and complications.

RESULTS

The success rate on preserving the uterus with the HYUNHO method was 96.2%. Three cases required additional procedures, including a cesarean hysterectomy or uterine artery embolization (UAE), two cases underwent a cesarean hysterectomy after delivery, and one case underwent UAE.

CONCLUSION

The HYUNHO method is a safe, easy method for placenta previa, although it should be evaluated in a randomized controlled trial.

Viral shedding of 2009 pandemic H1N1 and evaluation of quarantine recommendations

Public health authorities recommend that isolation precautions for influenza should be continued for 7 days after illness onset or until 24 h after the resolution of symptoms, whichever event lasts longer. However, little data are available regarding the duration of isolation for patients with 2009 pandemic H1N1 (pH1N1). We recruited patients with confirmed pH1N1 virus infection at a 2,000-bed tertiary care center. Influenza viral loads from oropharyngeal swab specimens were serially determined by reverse transcriptase quantitative polymerase chain reaction every other day, and the risk factors for prolonged viral shedding were investigated. To evaluate the current recommendations for isolation precautions, we measured the intervals between symptom onset and the last viral RNA detection, and that between the last viral RNA detection and the point at which the patient was symptom-free for 24 h. From November 2009 to January 2010, 26 patients were enrolled, and viral RNA was detected in more than half of the eligible patients (10 of 19, 52.6%) for ≥7 days after symptom onset. While evaluating the policy for lifting quarantine, we found that viral RNA was detected in 4 of 15 patients (26.7%) beyond the recommended duration of isolation. In conclusion, viral RNA was detected in a substantial proportion of hospitalized patients even when they fulfilled the recommended conditions for lifting quarantine, and we believe that more prudence is required in this aspect.

Use of Laryngeal Mask Airway and Its Removal in a Deeply Anaesthetized State Reduces Emergence Agitation after Sevoflurane Anaesthesia in Children

This study investigated the effect of laryngeal mask airway (LMA) and removal while in a deeply anaesthetized state (deep removal) compared with endotracheal tube and extubation when awake or deeply anaesthetized on the incidence of emergence agitation in children after sevoflurane anaesthesia for subumbilical surgery. Patients (2 – 7 years) were randomly assigned to one of three groups: ET-A group ( n = 56, endotracheal tube and extubation whilst awake); ET-D group ( n = 56, endotracheal tube and deep extubation); LMA-D group (n = 56, experienced LMA and deep removal). The incidence of postoperative emergence agitation was significantly lower in the LMA-D patients compared with patients in the ET-A group (21.4% and 41.1%, respectively). Patients in the LMA-D group required a significantly shorter stay in the postanaesthetic care unit (PACU) than ET-A patients. There were no significant differences in the incidence of postoperative emergence agitation or length of stay in the PACU between the ETA and ET-D groups, or between the ET-D and LMA-D groups. In conclusion, using an LMA and deep removal decreased postoperative emergence agitation compared with using an endotracheal tube and awake extubation after paediatric sevoflurane anaesthesia.

Stimulation of dendritic cells with Helicobacter pylori vacuolating cytotoxin negatively regulates their maturation via the restoration of E2F1

Helicobacter pylori induces an infiltration of dendritic cells (DCs) into the infected gastric mucosa. Although DCs play an important role in the regulation of inflammation, the effects of H. pylori vacuolating cytotoxin (VacA) on DC maturation process have not yet been elucidated. The role of VacA in DC maturation following co-exposure to Escherichia coli lipopolysaccharide (LPS) was investigated. The treatment of immature DCs with LPS up-regulated the expression of surface molecules [e.g. CD40, CD80, CD86 and major histocompatibility complex (MHC) class II], as well as the production of cytokines [e.g. interleukin (IL)-1β, IL-12p70 and tumour necrosis gactor (TNF)-α] compared with those of unstimulated controls. Co-stimulation with H. pylori VacA significantly reduced the up-regulated DC maturation markers induced by LPS. In addition, VacA sustained the immature state of DCs with high endocytosis and low migratory capacity. The LPS-induced down-regulation of E2F1 expression in DCs was recovered by co-stimulation with VacA. Moreover, suppression of E2F1 by small interfering RNA resulted in a significant recovery of the inhibited DC maturation by VacA. In contrast, VacA did not affect nuclear factor (NF)-κB responses to LPS and the NF-κB signal was not associated with VacA-induced inhibition of DC maturation. These results suggest that the exposure of DCs to H. pylori VacA negatively regulates DC maturation via the restoration of E2F1. The immunomodulatory action of VacA on DCs may contribute to the ability of VacA-producing H. pylori to establish a persistent infection in the gastric mucosa.

Characterization of Escherichia coli isolates from laying hens with colibacillosis on 2 commercial egg-producing farms in Korea

The present study reports on layer chickens with colibacillosis in 2 commercial egg-producing farms (referred to as farm A and farm B, which were managed by the same owner and were about 1 km apart) in the middle region of the Korean peninsula. The 2 flocks were infected at the initiation of egg laying. They were characterized by no previous clinical signs but sudden mortality (2.7-4.0%), with severe lesions of septicemia and fibrinous polyserositis. Escherichia coli was isolated from the lesions of the infected birds. Serotyping tests identified isolates that belonged to somatic groups O1 (12/17), O46 (2/17), O78 (1/17), and O84 (1/17) or that were unidentified (1/17). Thirteen of 17 E. coli isolates (76.4%) obtained from 11 birds in the 2 flocks showed similar pulsed-field gel electrophoresis patterns that were arbitrarily designated as pattern A. The isolates had high frequencies of putative virulence genes including 100% [fimC (type 1 fimbriae), iucD (aerobactin synthesis), and iss (increased serum survival)], 94.1% [cva/cvi (structural genes of colicin V operon) and vat (vacuolating autotransporter toxin)], 88.2% [irp2, iron-repressible protein (yersinia bactin) synthesis, and fyuA, ferric yersinia uptake], and 82.3% [tsh (temperature-sensitive hemagglutinin)]; astA (encoding a heat-stable cytotoxin associated with enteroaggregative E. coli) was not associated with the enteric disorder. These data suggest that all chickens with colibacillosis on farms A and B were likely infected by E. coli strains that are highly pathogenic in avian species.

The effect of human fetal liver-derived mesenchymal stem cells on CD34+ hematopoietic stem cell repopulation in NOD/Shi-scid/IL-2Rã(null) mice

Mesenchymal stem cells (MSCs) are progenitors that are capable of differentiating into mesenchymal tissues. They are known to support allogeneic hematopoietic stem cell transplantation by facilitating engraftment without increasing the risk of graft-versus-host disease. We optimized culture conditions for human fetal liver-derived MSCs (hFL-MSCs) to investigate the role of hFL-MSCs on repopulation of hematopoietic stem cells in NOD/Shi-scid/IL-2Rγ(null) (NOG) mice using CD34(+) hematopoietic stem cells (HSCs) derived from umbilical cord blood (UCB). FL-MSCs and CD34(+) HSCs were prepared from fetal liver and UCB, respectively. Twenty-four hours after irradiation, CD34(+) HSCs and hFL-MSCs were injected intravenously and intratibially into NOG mice. During 24 weeks posttransplantation, engraftment levels of human cells were analyzed in bone marrow, peripheral blood, and spleen of transplanted mice by flow cytometry. hFL-MSCs showed a fibroblast-like morphology and immunophenotypic characteristics appropriate for MSCs. hFL-MSCs prolonged the survival of NOG mice that had been cotransplanted with UCB CD34(+) cells. Fluorescence-activated cell-sorting analysis showed that engraftment of human cells was increased by cotransplantation of hFL-MSCs. However, significant enhancement of human cell engraftment was not detected in NOG mice regardless of the number of cotransplanted MSCs. Although survival of repopulating NOG mice and engraftment of human cells were prolonged by cotransplantation of hFL-MSCs, 8.0 × 10(6) MSCs were not sufficient to increase HSC engraftment in irradiated NOG mice in vivo.

Kidney donation after cardiac death in Korea

Organ donation after cardiac death (DCD) has been suggested due to the shortage of allografts in Korea. We investigated the outcomes of 446 deceased donor kidney transplant recipients in our center between September 1, 1995, and December 31, 2009. Twenty-four (5.4%) of those patients received DCD kidney grafts. The DCD group had a long intensive care unit stay, frequent inotropics use (such as norepinephrine and dopamine), low mean blood pressure and estimated glomerular filtration rate, and high serum creatinine and deceased donor scores compared to the standard criteria donor (SCD) group and the expanded criteria donor (ECD) group. Mean true warm ischemic time of the DCD group was 59.7 minutes based on asystole time. The DCD group had a long hospital stay after transplantation, but there was no statistically significant difference in delayed graft function and primary nonfunction. Serum creatinine levels at 3 months after transplantation in the ECD and DCD group were significantly higher than the SCD group (P < .001) but lower in the DCD group than in the ECD group at 6 months and 9 months (P < .001 and P = .004) posttransplantation. There were no statistically significant differences in serum creatinine levels or in the graft survival rates between groups at 12 months (P = .160 and P = .737). The use of DCD attracted Korean surgeons because DCD allografts are equivalent to a heart-beating donor. Donors who die during the evaluation of brain death should not be abandoned for procurement, and we need to try to harvest allografts after cardiac death (type 4 DCD) to expand donor pools.

A mechanism for the action of the compound DA-6034 on NF-κB pathway activation in Helicobacter pylori-infected gastric epithelial cells

DA-6034 is a synthetic derivative of eupatilin, a flavonoid with anti-inflammatory effects. The aim of this study was to investigate the effects of DA-6034 on the interactions between IκB kinase (IKK) and heat shock protein 90 (Hsp90), and activation of the nuclear factor-kappaB (NF-κB) signalling pathway in human gastric epithelial cells infected with Helicobacter pylori. MKN-45 gastric epithelial cell line was treated with DA-6034 and H. pylori. DA-6034 significantly inhibited NF-κB activation and upregulated the expressions of interleukin-8 (IL-8) and monocyte chemoattractant protein-1 in MKN-45 cells infected with H. pylori. However, DA-6034 did not influence activator protein-1 DNA binding activity in H. pylori-infected gastric epithelial cells. Pretreatment with DA-6034 attenuated the H. pylori-induced increase in IKK activity, and Hsp90 was associated with IKK-α and IKK-γ in MKN-45 cells. Treatment with DA-6034 dissociated the Hsp90 and IKK-γ complex in H. pylori-infected cells, leading to the inhibition of IL-8 expression. These results suggest that the eupatilin derivative 7-carboxymethyloxy-3',4',5-trimethoxy flavone has anti-inflammatory activity in gastric epithelial cells infected with H. pylori through the promotion of the dissociation of the IKK-γ-Hsp90 complex and suppression of NF-κB signalling.

Single nucleotide polymorphism association study for backfat and intramuscular fat content in the region between SW2098 and SW1881 on pig chromosome 6

This study was carried out to identify SNP associated with fatness traits on pig chromosome 6. In total, 11,067 putative genomic variations were detected in 125 complete bacterial artificial chromosome sequences corresponding to the region between SW2098 and SW1881, which harbors multiple QTL affecting intramuscular fat content (IMF) and backfat thickness (BFT). Among 173 putative SNP validated by MassArray, 120 SNP were used in an association study on 541 offspring produced by a cross of Korean native pig and Landrace breeds. The significance level of each SNP was determined using single marker regression analysis. Further, significant threshold values were determined using a false discovery rate. Nine out of 120 SNP showed significant effects on BFT or IMF or both. Of the 9 significant SNP, 4 were significantly associated with IMF, 7 were significantly related to BFT, and 2 SNP (Kps8172 and Kps6413) showed significant effects on both traits. Moreover, multiple regression analysis considering all significant SNP was used to correct spurious false positives due to linkage disequilibrium. Consequently, only 1 SNP (Kps6413) was significant for IMF, whereas 4 SNP including Kps6413 showed significant effects on BFT. The significant SNP had generally additive effects and on average explained 1.72% of the genetic variation for IMF and 3.92% for BFT, respectively. These markers can potentially be applied in pig breeding programs for improving IMF and BFT traits after validation in other populations.

Prevalence and different characteristics of two serotypes of Streptococcus parauberis isolated from the farmed olive flounder, Paralichthys olivaceus (Temminck and Schlegel), in Korea

The prevalence of two serotypes of Streptococcus parauberis isolated from the olive flounder, Paralichthys olivaceus, was evaluated in a total of 29 isolates between 2003 and 2010 in Korea. Streptococcus parauberis isolates were divided into two serologically distinct types (serotype 1 and serotype 2), except for one strain (S1091), using an agglutination assay with rabbit antiserum, and serotype 1 was identified as the dominant type (24 of 29 isolates) in this study. To identify the characteristics of the two serotypes of S. parauberis, we conducted a biochemical test using the API 20 Strep kit, a transmission electron microscopy (TEM) assay, sequence analysis of 16S-23S rRNA intergenic spacer region (ISR) and a pathogenicity test. In TEM, both serotypes possessed polysaccharide capsule layers around the cell surface when bacterial cells were treated with a homologous serotype of rabbit antiserum. However, we were unable to discriminate serotype-specific biochemical characteristics and genetic characteristics of 16S-23S rRNA ISR between the two serotypes. In the pathogenicity test, the serotype 1 strains induced significantly higher mortality than the serotype 2 strains in olive flounder when experimentally inoculated via the intraperitoneal route.

Resistance to carbapenems in sequence type 11 Klebsiella pneumoniae is related to DHA-1 and loss of OmpK35 and/or OmpK36

This study investigated the molecular mechanisms of carbapenem resistance in clinical isolates of Klebsiella pneumoniae from Korea and the clinical outcomes of resistant K. pneumoniae infection. Sixteen K. pneumoniae isolates showing resistance to carbapenems collected from a tertiary-care hospital were examined for the mechanisms of carbapenem resistance. PCR and sequencing experiments detected the bla(DHA-1) AmpC β-lactamase gene in all 16 clinical isolates, whilst the bla genes of extended-spectrum β-lactamases were detected in 12 of 16 isolates. SDS-PAGE experiments indicated that all the isolates lacked the 35 kDa and/or 36 kDa outer-membrane proteins (OMPs). Sequence analysis of the corresponding OMP genes revealed various alterations. PFGE analysis demonstrated that there were no major clonal relationships among the K. pneumoniae isolates. However, multilocus sequence typing experiments showed that all isolates shared the same sequence type (ST), ST11, except for one isolate of ST48. The crude mortality rate of infected patients was 81.8 %. Carbapenem resistance was mainly due to a combination of DHA-1 AmpC β-lactamase coupled with the loss of OmpK35 and/or OmpK36 and was associated with poor clinical outcome.

Effects of p.C430S polymorphism in the PPARGC1A gene on muscle fibre type composition and meat quality in Yorkshire pigs

The peroxisome proliferator-activated receptor-gamma coactivator-1A (encoded by PPARGC1A) is involved in the formation of type I fibres. Therefore, the PPARGC1A gene can be considered as a functional candidate gene for muscle fibre type composition and meat quality in pigs. The aim of this study was to investigate the associations of the p.C430S polymorphic site in exon 8 of the PPARGC1A gene with muscle fibre characteristics and meat quality traits. The polymorphism was genotyped by PCR-RFLP using AluI restriction enzyme on a total of 152 Yorkshire pigs. Statistical analyses revealed that the p.C430S genotypes significantly affected number (P < 0.05) and area (P < 0.01) of type I muscle fibre, and were significantly associated with muscle pH (P < 0.001) and lightness(P < 0.01). On the basis of these results, we suggest that the p.C430S polymorphism can induce variation of type I fibre formation in porcine longissimus dorsi muscle and that it can be used as a meaningful molecular marker for better meat quality.

Low plasma levels of the soluble receptor for advanced glycation end products in HIV-infected patients with subclinical carotid atherosclerosis receiving combined antiretroviral therapy

OBJECTIVE

Combined antiretroviral therapy (cART) has significantly improved the survival rate and quality of life for HIV-infected subjects, but it contributes to the development of metabolic complications including coronary artery disease (CAD). Recent studies have reported that high plasma levels of the soluble receptor for advanced glycation end products (sRAGE) were associated with a lower incidence of CAD in non-HIV infected patients. However, there has been no report of an association of sRAGE and subclinical carotid atherosclerosis in HIV-infected patients receiving cART.

METHODS

We examined the association of circulating sRAGE in HIV-infected patients with carotid intima-media thickness (IMT) and other metabolic variables. We prospectively enrolled 76 HIV-infected patients receiving cART for ≥ 6 months.

RESULTS

sRAGE had a significantly negative correlation with body mass index (r = -0.324, p = 0.005), waist-to-hip ratio (r = -0.335, p = 0.003), systolic blood pressure (BP) (r=-0.359, p=0.002), diastolic BP (r = -0.343, p = 0.004), total cholesterol (r = -0.240, p = 0.037), low-density lipoprotein-cholesterol (r=-0.284, p=0.024), log(homeostasis model assessment of insulin resistance [HOMA-IR]) (r = -0.380, p = 0.002) and carotid IMT including max-IMT and mean-IMT (r = -0.358, p = 0.001 and r = -0.329, p = 0.004, respectively). By the use of multiple stepwise regression analyses, systolic BP (p=0.001) and log[HOMA-IR] (p = 0.001) remained significant independently.

CONCLUSIONS

These results suggest that sRAGE may have a protective effect against subclinical atherosclerosis by preventing inflammatory responses mediated by the activation of cell surface RAGE in HIV-infected patients receiving cART.

Clinical features and outcomes of acute kidney injury among patients with acute hepatitis A

BACKGROUND

Although acute hepatitis A is usually self-limited, the clinical manifestations can vary from mild to severe liver dysfunction. However, little is known about risk factors for and outcomes of acute kidney injury (AKI) in acute hepatitis A.

OBJECTIVES

To identify the risk factors for and outcomes of AKI in acute hepatitis A.

STUDY DESIGN

We identified 396 patients with acute hepatitis A, which registered between January 2006 and June 2009 at a tertiary care university hospital. Retrospective case-control studies were conducted in order to identify risk factors for AKI.

RESULTS

Thirty patients (7.6%) developed AKI. On multivariate analysis, fulminant hepatitis, leukocytosis, and elevated CRP were independent risk factors for AKI associated with hepatitis A, and higher total bilirubin, leukocytosis, and elevated CRP were independent risk factor for AKI within nonfulminant hepatitis A. Of the 30 patients with AKI, 23 (76.7%) patients fully recovered, 2 patients maintained hemodialysis after hospital discharge and 5 patients died due to hepatic failure without recovery from AKI. Among 20 patients with AKI in nonfulminant subgroup, 19 patients (95%) recovered without hemodialysis.

CONCLUSIONS

AKI is not a rare complication of acute hepatitis A and severity of hepatitis and hepatic injury influence the development of AKI in acute hepatitis A.

Clinical review of endogenous endophthalmitis in Korea: a 14-year review of culture positive cases of two large hospitals

PURPOSE

To identify the clinical features and outcomes of endogenous endophthalmitis in Korea.

MATERIALS AND METHODS

We reviewed 18 patients with endogenous endophthalmitis at 2 Korean hospitals, treated over a 14 year period between January 1993 and December 2006.

RESULTS

The comorbidities observed in these cases were diabetes mellitus and liver cirrhosis. The most common pathogens, which were found in 7 patients each (38.9%), were Klebsiella pneumonia and Pseudomonas aeruginosa. All patients were treated with systemic antibiotics and fortified topical antibiotics. A surgical approach including vitrectomy was performed in 9 cases (50.0%). The prognosis was generally poor, and visual acuity improved slightly in 6 patients (33.3%).

CONCLUSION

In this study, diabetes mellitus and Klebsiella pneumonia showed a close relationship with endogenous endophthalmitis, respectively. Endogenous endophthalmitis is a serious risk to sight and careful attention to establishing the diagnosis and management may decrease the ocular morbidity.

Lack of effect of dexamethasone on growth of Orientia tsutsugamushi Gilliam in mouse L929 cells

PURPOSE

Previous studies and our own clinical experience suggest that concurrent corticosteroid treatment for severe rickettsial disease with multiorgan failure may improve the clinical course or reduce mortality. However, the use of corticosteroids as adjunctive treatment for rickettsial diseases is controversial. We attempted to determine the influences of corticosteroid on the growth of Orientia tsutsugamushi in vitro to justify and evaluate the clinical applicability of corticosteroid in rickettsial disease.

MATERIALS AND METHODS

L929 cells were infected with Orientia tsutsugamushi Gilliam. Dexamethasone was added to the cells at final concentrations of 10¹ and 10⁷ pg/mL. Cultures were incubated at 35°C and processed for flow cytometry on the 6th day after addition of dexamethasone.

RESULTS

Observation on the 6th day after treatment with dexamethasone in infected cultures revealed that there was no difference in fluorescence intensity among the treatment wells. Treatment of the cells with dexamethasone at concentrations of 10¹ and 10⁷ pg/mL showed no influence on the growth of Orientia tsutsugamushi.

CONCLUSION

Our results to show that isolated corticosteroid does not enhance the replication of Orientia tsutsugamushi in vitro. Concurrent use of anti-inflammatory or immunosuppressive doses of corticosteroids in conjunction with antibiotics may not have detrimental effects on the course of scrub typhus.