Clustering and multiple-spreading events of nosocomial severe acute respiratory syndrome coronavirus 2 infection

Background

There is growing evidence that super-spreading events (SSEs) and multiple-spreading events (MSEs) are a characteristic feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, data regarding the possibility of SSEs or MSEs in healthcare settings are limited.

Methods

This study was performed at a tertiary-care hospital in Korea. We analysed the nosocomial COVID-19 cases that occurred in healthcare workers and inpatients and their caregivers between January and 20^th December 2020. Cases with two to four secondary cases were defined as MSEs and those with five or more secondary cases as SSEs.

Findings

We identified 21 nosocomial events (single-case events, N = 12 (57%); MSE + SSE, N = 9 (43%)) involving 65 individuals with COVID-19. Of these 65 individuals, 21 (32%) were infectors. The infectors tended to have a longer duration between symptom onset and diagnostic confirmation than did the non-infectors (median two days vs zero days, P=0.08). Importantly, 12 (18%) individuals were responsible for MSEs and one (2%) for an SSE, which collectively generated 35 (54%) secondary cases.

Conclusion

In a hospital with thorough infection-control measures, approximately 70% of the nosocomial cases of COVID-19 did not generate secondary cases, and one-fifth of the infectors were responsible for SSEs and MSEs, which accounted for approximately half of the total cases. Early case identification, isolation, and extensive contact tracing are important for the prevention of transmission and SSEs.

Characterization of novel monoclonal antibodies against MERS-coronavirus spike protein

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Identification of neutralizing mAbs using MERS-CoV spike-pseudotyped virus.

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Transmembrane domain-deleted spike subunit protein induced neutralizing antibodies.

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Neutralizing antibodies could bind to RBD of MERS-CoV spike, but not vice versa.

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Mutation in residue 506–509 or 529 of S elicits neutralization escape of MERS-CoV.

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Our mAbs can be utilized for identification of specific mutation of MERS-CoV.

Middle East Respiratory Syndrome coronavirus (MERS-CoV) causes severe pulmonary infection, with ∼35 % mortality. Spike glycoprotein (S) of MERS-CoV is a key target for vaccines and therapeutics because S mediates viral entry and membrane-fusion to host cells. Here, four different S subunit proteins, receptor-binding domain (RBD; 358–606 aa), S1 (1–751 aa), S2 (752–1296 aa), and SΔTM (1–1296 aa), were generated using the baculoviral system and immunized in mice to develop neutralizing antibodies. We developed 77 hybridomas and selected five neutralizing mAbs by immunization with SΔTM against MERS-CoV EMC/2012 strain S-pseudotyped lentivirus. However, all five monoclonal antibodies (mAb) did not neutralize the pseudotyped V534A mutation. Additionally, one mAb RBD-14F8 did not show neutralizing activity against pseudoviruses with amino acid substitution of L506 F or D509 G (England1 strain, EMC/2012 L506 F, and EMC/2012 D509 G), and RBD-43E4 mAb could not neutralize the pseudotyped I529 T mutation, while three other neutralizing mAbs showed broad neutralizing activity. This implies that the mutation in residue 506–509, 529, and 534 of S is critical to generate neutralization escape variants of MERS-CoV. Interestingly, all five neutralizing mAbs have binding affinity to RBD, although most mAbs generated by RBD did not have neutralizing activity. Additionally, chimeric antibodies of RBD-14F8 and RBD-43E4 with human Fc and light chain showed neutralizing effect against wild type MERS-CoV KOR/KNIH/002, similar to the original mouse mAbs. Thus, our mAbs can be utilized for the identification of specific mutations of MERS-CoV.

Abstract P1-09-12: TP53 expression in relation to clinical and etiologic factors in breast cancer subtypes

TP53 is a well-known tumor suppressor gene and mutations in TP53 are the most frequent genomic event in most cancers including breast cancer. Recent studies have shown that the frequency, spectrum, timing, and clinical implications of TP53 mutations varied in different molecular subtypes of breast cancer. For example, the frequency of TP53 mutations is the highest in basal-like subtype and lowest in luminal A tumors. However, the evaluation of TP53 protein expression, as a surrogate for TP53 mutations, in large studies in the context of tumor subtypes is limited. In addition, the etiologic relevance of TP53 expression is yet to be investigated. The goal of this study is to evaluate the association of clinical and breast cancer risk factors with TP53 expression, measured using immunohistochemistry (IHC), in breast cancer molecular subtypes. The analysis included 7,226 women with invasive breast cancer who were diagnosed and treated in a tertiary hospital in Beijing, China. Subtypes were defined as Luminal A: ER+ and PR+, HER2–, and low grade (grades 1 or 2); luminal B/HER2–: ER+ and/or PR+, HER2–, and high grade (grade 3); luminal B/HER2+: ER+ and/or PR+, HER2+ (regardless of grade); HER2-enriched: ER–, PR–, and HER2+; Triple-negative (TN): ER–, PR–, and HER2–. As expected, positive TP53 staining showed the lowest frequency in the luminal A (46%) and highest in the TN (61%) and HER2-enriched (63%) subtypes (P-value <0.001). Overall and particularly in luminal A patients, positive TP53 staining was associated with higher frequencies of aggressive tumor features such as higher grade, larger tumor size, higher proliferative index, and EGFR expression. Compared with TP53– patients, TP53+ patients were more likely to have younger ages at onset and increased parity, but these associations were largely driven by the luminal A subtype [OR (95% CI) vs nulliparity = 2.67 (1.59, 4.51); 2.63 (1.52, 4.55); 3.68 (2.01, 6.72) for 1, 2, and ≥3 children, respectively (P-trend = 0.006)]. Luminal A/TP53+ patients were also more likely to have breastfed [OR (95% CI) ever vs never = 1.38 (1.03, 1.85)] than luminal A/TP53– patients. These findings suggest that TP53 IHC staining might be used to further refine the classification of luminal A breast cancer into subgroups with distinct clinical and etiologic relevance.

Citation Format: Yang XR, Abubakar M, Guo C, Koka H, Sung H, Guida J, Deng J, Zhou B, Hu N, Lu N. TP53 expression in relation to clinical and etiologic factors in breast cancer subtypes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-09-12.

Assessment of an Epoxy-Fixed Pericardial Patch with or without Ionically Bound Heparin in a Canine Model

In this study, an epoxy-fixed porcine pericardia I patch with or without ionically bound heparin was evaluated in a canine model as an alternative to the glutaraldehyde-fixed biological patch for clinical applications. To evaluate the effectiveness of this epoxy-fixed patch, a composite membrane composed of: an epoxy-fixed porcine patch with ionically bound heparin; a glutaraldehyde-fixed porcine patch with ionically bound heparin; an ePTFE polymeric patch; a polyester polymeric patch; an epoxy-fixed porcine patch without ionically bound heparin; and a glutaraldehyde-fixed porcine patch without ionically bound heparin was made. This membrane was assessed orthopically in a canine model. The early results (1-4 weeks post implant) revealed that the biological patches with ionically bound heparin had the mildest tissue reactions (inflammatory reaction, fibrosis, and adhesion) among all the test samples. However, by 12 weeks postoperatively, all the test samples had mild to severe tissue reactions. The order of tissue reactions with increasing severity was: the biological patches with ionically bound heparin, the biological patches without ionically bound heparin, and the polymeric patches. The results suggest that heparin may be used to reduce adhesion. Additionally, the epoxy-fixed tissue caused a relatively lower degree of inflammatory reaction than the glutaraldehyde-fixed tissue.

Molecular epidemiology and environmental contamination during an outbreak of parainfluenza virus 3 in a haematology ward

Background

Although fomites or contaminated surfaces have been considered as transmission routes, the role of environmental contamination by human parainfluenza virus type 3 (hPIV-3) in healthcare settings is not established.

Aim

To describe an hPIV-3 nosocomial outbreak and the results of environmental sampling to elucidate the source of nosocomial transmission and the role of environmental contamination.

Methods

During an hPIV-3 outbreak between May and June 2016, environmental surfaces in contact with clustered patients were swabbed and respiratory specimens used from infected patients and epidemiologically unlinked controls. The epidemiologic relatedness of hPIV-3 strains was investigated by sequencing of the haemagglutinin–neuraminidase and fusion protein genes.

Findings

Of 19 hPIV-3-infected patients, eight were haematopoietic stem cell recipients and one was a healthcare worker. In addition, four had upper and 12 had lower respiratory tract infections. Of the 19 patients, six (32%) were community-onset infections (symptom onset within <7 days of hospitalization) and 13 (68%) were hospital-onset infections (≥7 days of hospitalization). Phylogenetic analysis identified two major clusters: five patients, and three patients plus one healthcare worker. Therefore, seven (37%) were classified as nosocomial transmissions. hPIV-3 was detected in 21 (43%) of 49 environmental swabs up to 12 days after negative respiratory polymerase chain reaction conversion.

Conclusion

At least one-third of a peak season nosocomial hPIV-3 outbreak originated from nosocomial transmission, with multiple importations of hPIV-3 from the community, providing experimental evidence for extensive environmental hPIV-3 contamination. Direct contact with the contaminated surfaces and fomites or indirect transmission from infected healthcare workers could be responsible for nosocomial transmission.

Phenotypic changes of methicillin-resistant Staphylococcus aureus during vancomycin therapy for persistent bacteraemia and related clinical outcome

Persistent bacteraemia (PB) due to methicillin-resistant Staphylococcus aureus (MRSA) that fails to respond to glycopeptide therapy is a well-documented clinical problem. There are limited data on changes in agr functionality, vancomycin susceptibility and heteroresistance during MRSA PB. Thus, the frequency of these changes and their clinical significance remain unclear. Only patients with MRSA PB (≥7 days) from a prospective cohort of S. aureus bacteraemia were included. We collected isogenic paired strains and compared vancomycin MIC, vancomycin heteroresistance, and agr functionality between initial and final blood isolates. We also assessed the clinical outcome. A total of 49 patients had MRSA PB over 22 months. Bacteraemia persisted for a median of 13 days and most patients (98%) received glycopeptide as initial therapy. Among 49 isogenic pairs, only one pair showed a vancomycin MIC increase ≥2-fold by broth microdilution method, and only seven (14%) by E-test. Significant portions of initial isolates had vancomycin heteroresistance (49%) and agr dysfunction (76%). Development of vancomycin heteroresistance during PB occurred in four (16%) among 25 initial vancomycin-susceptible isolates, and acquisition of agr dysfunction occurred in two (16%) among 12 initial agr-functional isolates. Changes in the opposite direction occasionally occurred. These phenotypic changes during PB were not associated with mortality, whereas agr dysfunction of the initial isolates was significantly associated with mortality. During MRSA PB, phenotypic changes of MRSA isolates occurred occasionally under prolonged vancomycin exposure but were not significantly associated with clinical outcome. In contrast, initial agr dysfunction could be a predictor for mortality in MRSA PB.

Subspecies distribution and macrolide and fluoroquinolone resistance genetics of Mycobacterium abscessus in Korea

BACKGROUND

Treating Mycobacterium abscessus infections with antimicrobials remains difficult, possibly due to drug resistance.

OBJECTIVE

To investigate the subspecies distribution of M. abscessus and its correlation with antibiotic susceptibility and the genetics of antibiotic resistance, focusing on macrolides and fluoroquinolones, in the Republic of Korea.

DESIGN

A total of 53 M. abscessus isolates were identified to the subspecies level by sequencing of hsp65 and erm(41). The minimal inhibitory concentrations (MICs) of clarithromycin (CLM) and ciprofloxacin (CFX) were determined using Sensititre™ RAPMYCO plates. The rrl, gyrA and gyrB genes were sequenced to elucidate the molecular mechanisms of macrolide and fluoroquinolone resistance.

RESULTS

Isolates included 22 M. abscessus subsp. abscessus and 31 M. abscessus subsp. bolletii. erm(41) sequences showing subspecies-specific deletions and sequence variations in the 28th nucleotide were concordant with inducible CLM resistance; however, mutations in rrl were not detected. Low- and high-level CFX resistance was observed in respectively 19 (35.8%) and 10 (18.9%) of the 53 clinical isolates, regardless of subspecies. However, no non-synonymous mutations were detected in gyrA or gyrB.

CONCLUSION

Sequencing of the erm gene and subspeciation of M. abscessus may be used to predict inducible macrolide susceptibility. Further studies of the relationship between specific mutations in gyrA or gyrB to MIC change are required.

Emergence of Panton-Valentine leucocidin-positive ST8-methicillin-resistant Staphylococcus aureus (USA300 clone) in Korea causing healthcare-associated and hospital-acquired bacteraemia

Panton-Valentine leucocidin (PVL)-positive sequence type (ST)8-MRSA-SCCmec IVa (USA300) is the epidemic strain of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in North America. USA300 is extremely rare in South Korea, and PVL-negative ST72 SCCmec type IVc is the predominant CA-MRSA clone. In a multicentre, prospective cohort study of S. aureus bacteraemia, we identified PVL-positive ST8-MRSA isolates by performing multilocus sequence typing and PCR for PVL. We analyzed the clinical characteristics of patients with PVL-positive ST8-MRSA bacteraemia, and performed SCCmec, spa, and agr typing, PCR for arginine catabolic mobile element (ACME), virulence gene profiling, and pulsed-field gel electrophoresis (PFGE). Among a total of 818 MRSA isolates, we identified ten isolates of PVL-positive ST8-MRSA (USA300) (3 from Hospital D, 4 from Hospital G, and 3 from Hospital A), all of which involved exclusively healthcare-associated (5 isolates) and hospital-acquired bacteraemia (5 isolates). This strain accounted for 8~10 % of the hospital-acquired MRSA bacteraemia in Hospitals D and G. Bacteraemia of unknown origin was the most common type of infection followed by pneumonia. All the isolates were SCCmec type IVa, spa type t008, and agr group I. Eight of the isolates harboured ACME. In a PFGE analysis, four isolates were identical to the USA300 control strain, five differed by a single band, and the remaining one differed by two bands. All the isolates were pulsed-field type USA300. This is the first report of healthcare-associated and hospital-acquired bacteraemia caused by USA300 in South Korea. USA300 seems to be an emerging hospital clone in this country.

Abstract P6-10-10: Association between mammographic density and breast cancer subtypes among Chinese women

Epidemiological studies have shown that associations between breast cancer risk and risk factors vary by tumor pathology such as estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) status. Mammographic density (MD) is a strong risk factor for breast cancer, but data on the association between MD and breast cancer subtypes have been inconsistent and most studies have been conducted among Western women. The goal of this study was to evaluate the association between MD and breast cancer subtypes in an Asian population where the proportion of dense breast tissue is higher but the overall breast cancer incidence rate is much lower compared with Western countries. Breast cancer cases from a cancer hospital in Beijing, China with MD and ER, PR, and HER2 immunohistochemical (IHC) data were included in this analysis. To reduce subtype misclassification, we excluded cases that were HER2 2+ for IHC but had no FISH data. Tumor subtypes were defined as Luminal A (ER+ or PR+ and HER2-, N=376), Luminal B (ER+ or PR+ and HER2+, N=97), HER2-overexpressing (ER- and PR- and HER2+, N=71), and triple negative (TN, ER- and PR- and HER2-, N=66). MD was assessed on digital mammograms and categorized into four levels using the Breast Imaging Reporting and Data System (BI-RADS) scoring system (a=almost entirely fat, b=scattered fibroglandular densities, c=heterogeneously dense, and d=extremely dense). Because there were few cases with almost entirely fat breasts, we combined MD levels "a" and "b" as our reference group. Polychotomous logistic regression was used to assess the association between MD and breast cancer subtypes with the adjustment of age, menopausal status, parity, age at menarche, and body mass index (BMI) since all these variables showed significant inverse associations with MD (P=0.002 for age at menarche and P&lt;0.0001 for all others). Compared with luminal A cases, cases with HER2-overexpressing tumors were significantly more likely to have extremely dense breasts (Odds ratio [OR], 2.6; 95% confidence interval [CI], 1.2-5.7). Cases with luminal B (OR, 2.1, 95% CI, 1.2-3.9) and TN (OR, 2.9, 95% CI, 1.5-5.8) tumors had significantly higher proportions of heterogeneously dense but not extremely dense tissue compared with luminal A cases. Our data suggest that higher MD is associated with more aggressive tumor subtypes, particularly the HER2-overexpressing subtype among Chinese breast cancer cases. If confirmed in larger studies, these results may provide insight into the higher incidence rates of HER2-overexpressing breast cancer seen among young Asian American and Asian women.

Citation Format: Yang XR, Li J, Li E-N, Guida JL, Li M, Sung H, Lu N, Hu N, Gierach GL. Association between mammographic density and breast cancer subtypes among Chinese women. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-10.

Long-term follow up of HIV-1-infected Korean haemophiliacs, after infection from a common source of virus

In the early 1990s, 20 haemophiliacs (HPs) were infected with a common source of HIV-1 viruses through the contaminated clotting factor IX. The aim of this study is to review 20 HPs infected with a common source of virus. The enrolled patients have been consecutively treated with Korean red ginseng (KRG), zidovudine (ZDV) or two-drug therapy and highly active antiretroviral therapy (HAART). We determined full-length pol gene over 20 years and human leukocyte antigen (HLA) class I with peripheral blood mononuclear cells and reviewed medical records. Eighteen HPs experienced various opportunistic infections or clinical manifestations. There were significant inverse correlations between the HLA prognostic score and the annual decrease in CD4+ T-cell counts prior to HAART (AD) (P < 0.05) and the amount of KRG and the AD (P < 0.01). From 1998, the HPs had been treated with HAART. Each of the two patients died without and with HAART regimen respectively. At present, 16 HPs have been alive with HAART. Among the 16 HPs, 12 and 4 are on HAART-plus-KRG and HAART only respectively. Eleven HPs including 2 HPs with G-to-A hypermutations had revealed resistance mutations. Ten and two HPs have shown poor adherence and incomplete viral suppres-sion on HAART respectively. Virological failure based on WHO guidelines was not observed on KRG-plus-HAART. Two HPs revealed additional resistance mutations against two classes on KRG-plus-HAART. As a nationwide study, we first report overall features on clinical course of Korean haemophiliacs. Further education on the importance of drug adherence is needed.

Fatal scedosporiosis in multiple solid organ allografts transmitted from a nearly-drowned donor

Scedosporium spp. is the most common mold infection in pneumonia resulting from near-drowning. Three fatal scedosporiosis cases developed after solid organ transplantation, probably transmitted from the nearly-drowned donor. One heart transplant recipient and two kidney transplant recipients developed fatal scedosporiosis following deceased donor transplantation from the same donor, a nearly-drowned victim of a suicide attempt. Genotypically, indistinguishable strains of Scedosporium auratiacum were recovered from the three recipients. Two liver transplant recipients from the same donor received prophylactic voriconazole without any subsequent signs of infection. To determine the safety of donation from nearly-drowned donors, a national traceback investigation was also performed of the causes of deaths in all transplant recipients who received organs from drowned donors between 2001 and 2013. Over 13 years, 2600 deceased donor transplants were performed in Korea. Among these 2600 deceased donor transplants, 27 (1%) victims of drowning donated their organs. From these 27 donors, 84 patients received organ transplants and 18 died, including the above three. We found no microbiologic evidence of invasive mold transmission from the nearly-drowned donors to the other 15 recipients. Although disseminated infection in the donor could not be demonstrated by culture, undiagnosed disseminated donor infection and transmission of Scedosporium spp. should be considered in near-drowning events.

Comparison of the clinical characteristics of Mycobacterium tuberculosis and nontuberculous mycobacteria patients with joint involvement

Nontuberculous mycobacteria (NTM) joint involvement is rare. However, the incidence of NTM disease is increasing and it is difficult to distinguish NTM from Mycobacterium tuberculosis (MTB). Here, the clinical characteristics of NTM joint involvement were compared with those of MTB. Distal joint involvement and precipitating factors were significantly more frequent for NTM joint infections. Because pathologic findings of NTM and MTB were similar, microbiological investigations are needed.

Synchronous infection with Mycobacterium chelonae and Paecilomyces in a heart transplant patient

A 41-year-old male who was 3 years status post heart transplant presented with a 3-month history of painful erythematous nodules and ulcers on his lower legs and right hand. First, Mycobacterium chelonae infection was revealed through several biopsies with molecular sequence analysis, and combination treatment, including clarithromycin, was started. During the treatment, lesions of the legs showed an improvement, but a fluctuant erythematous nodule on the thumb did not respond. Repetitive biopsy from the thumb ultimately identified Paecilomyces species and the patient was treated with itraconazole and terbinafine sequentially. Our case is the first report, to our knowledge, of synchronous infection with non-tuberculous mycobacteria (NTM) and Paecilomyces in a solid organ transplant recipient. Our findings highlight the importance of recognizing cutaneous NTM infections or deep mycoses, as well as the importance of choosing an appropriate treatment.

Cooperative interactions of PTEN deficiency and RAS activation in melanoma metastasis

Mitogen-activated protein kinase (MAPK) and AKT pathways are frequently co-activated in melanoma through overexpression of receptor tyrosine kinases, mutations in their signaling surrogates, such as RAS and BRAF, or loss of negative regulators such as PTEN. As RAS can be a positive upstream regulator of PI3-K, it has been proposed that the loss of PTEN and the activation of RAS are redundant events in melanoma pathogenesis. Here, in genetically engineered mouse models of cutaneous melanomas, we sought to better understand the genetic interactions between HRAS activation and PTEN inactivation in melanoma genesis and progression in vivo. We showed that HRAS activation cooperates with Pten+/- and Ink4a/Arf-/- to increase melanoma penetrance and promote metastasis. Correspondingly, gain- and loss-of-function studies established that Pten loss increases invasion and migration of melanoma cells and non-transformed melanocytes, and such biological activity correlates with a shift to phosphorylation of AKT2 isoform and E-cadherin down-regulation. Thus, Pten inactivation can drive the genesis and promote the metastatic progression of RAS activated Ink4a/Arf deficient melanomas.

Prognostic significance of serum vascular endothelial growth factor per platelet count in gastric cancer patients

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Background: Recent studies have shown that VEGF expression not in tissues but in serum sample is correlated with tumor vascularity, and high serum VEGF levels could predict poor prognosis in cancer patients. However there are limited data regarding the clinical and prognostic significance of serum VEGF levels per platelet count in advanced gastric cancer. In this study, we conducted a study to evaluate the prognostic implication of serum VEGF per platelet count in patients with advanced gastric cancer. Methods: 111 patients with histologically confirmed gastric cancer, 10 patients with early gastric cancer were included and control serum samples were acquired from 10 healthy volunteers. The levels of VEGF were measured using human VEGF quantitative enzyme-linked immunosorbent assay (ELISA). Survival curves were calculated using the Kaplan-Meier method and survival comparisons were made by the log rank test in metastatic gastric cancer. The Cox proportional hazards regression model was utilized for multivariate analyses after univariate analysis defined relevant prognostic variables. Results: A trend toward a significant positive correlation between serum VEGF and platelet counts was observed in patients of AGC (r = 0.477, P = 0.000) and there was a significant correlation between serum VEGF levels and differentiation of tumor (p = 0.014), stage (p = 0.036). The overall survival (log rank, p =0.0432) and the progression free survival (median 4.5 vs. 8.9 months; log rank, p =0.0116) were significantly shorter in patients with high VEGF per platelet count (≥1.626 pg/106). In the multivarivate analysis, performance status (P=0.025), the presence of peritoneal carcinomatosis (P=0.006), serum VEGF per platelet (P=0.005) were found to be significantly associated with poor progression free survival. Conclusions: This study demonstrated that serum VEGF per platelet count are correlated with poor overall survival and progression free survival in patients with advanced gastric cancer. Therefore measurement of serum VEGF per platelet might be useful markers for predicting disease progression and prognosis of advanced gastric cancer.

No significant financial relationships to disclose.

Parainfluenza virus 3 pneumonia in a kidney transplant recipient

We report the first case of parainfluenza virus type 3 (PIV3) pneumonia in a kidney transplant recipient. A 39-year-old man developed pneumonia during hospitalization 6 years after kidney transplantation. He became hypoxic and underwent noninvasive ventilation. PIV3 was detected in the bronchoalveolar lavage fluid. He was treated successfully with aerosolized ribavirin and intravenous immunoglobulin. Although he recovered from pneumonia, his graft function deteriorated and he had to restart peritoneal dialysis.

Phase II trial of oxaliplatin, 5-FU, and leucovorin chemotherapy for the previously treated patients with advanced gastric cancer

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Background: The effect of chemotherapy for advanced gastric cancer was disappointing. Most of patients have progressed after treatment of first line chemotherapy. So, many trials searching for effective combination chemotherapy to these patients are warranted. We conducted this study to ascertain the efficacy and toxicity of oxaliplatin, 5FU, and leucovorin combination chemotherapy for the previously treated patients with advanced gastric cancer. Methods: In all, 48 patients received course of oxaliplatin 100mg/m2 intravenously (i.v) for 2hour and leucovorin at 100mg/m2 intravenously (i.v) for 2hour on day 1, then 5FU 2.4 g/m2 i.v for 46 hour continuous infusion on day 1 and 2. This regimen was repeated every 2 weeks. Results: A total 220 courses were administered as second line (64.6%) and third line (29.2%), and median number of courses per patient was four. No complete response was reported and 7 partial responses (14.6%) were achieved, giving an overall disease stabilizing rate of 52.2% (95% Confidence interval, 37.85 % to 66.6%). The major toxicity was neutropenia, which reached grade 3/4 in 8 patients (16.7%). Median time to progression was 3 months (0.6 to 8 months), median survival duration was 8 months (0.5+ to 14.5 months), and median response duration was 3 months (1.6–4.3 months). Conclusions: We conclude that oxaliplatin, 5-FU, leucovorin combination chemotherapy for the treatment of previously treated advanced gastric cancer has a role for disease stabilizing and toxicity was tolerable to most of patients.

No significant financial relationships to disclose.

Molecular epidemiologic study of a human immunodeficiency virus 1 outbreak in haemophiliacs B infected through clotting factor 9 after 1990

BACKGROUND AND OBJECTIVES

Twenty haemophiliacs were diagnosed as infected with human immunodeficiency virus 1 (HIV-1), 1 to 2 years after exposure to clotting factor 9 manufactured in Korea, beginning in early 1990. This study assessed the genetic relationships between viruses found in plasma donors and haemophiliacs.

MATERIALS AND METHODS

Sequencing of the nef and pol genes of viruses from infected haemophiliacs, plasma donors whose plasma was used in domestic clotting factor manufacture, haemophiliacs infected outside Korea, and local controls were determined by nested polymerase chain reactions and direct DNA sequencing. Phylogenetic analysis was used to investigate the relationships among the sequences.

RESULTS

Both plasma donors and the haemophiliacs were infected with a subclade of subtype B that is a founder effect lineage in Korea.

CONCLUSION

Our data indicate that HIV-1 transmission to 20 haemophiliacs occurred through intravenous injection of Korean-made clotting factor.

SUMMARY

A clotting factor made in Korea from blood from cash-paid donors infected at least 20 haemophiliacs with HIV-1 subtype B.

A phase II of high dose capecitabine plus irinotecan for patients with advanced or metastatic gastric cancer: preliminary results

14086

Background: Capecitabine is the prodrug of 5-FU to generate maximal tumor activity in tumor site and/or improve the tolerability, has demonstrated the synergistic activity with irinotecan in some solid cancers . Previous study showed the dose intensification of capecitabine increased the response rate with comparable toxicities in metastatic colorectal cancer. We conducted this study to ascertain the efficacy and toxicity of irinotecan and high dose capecitabine combination chemotherapy for chemotherapy-naïve advanced or metastatic gastric cancer. Methods: Patients who were advanced or metastatic gastric cancer and have not received any chemotherapeutic drug except adjuvant chemotherapy, received irinotecan 130mg/m2 intravenously (i.v) for 90 min on day 1 and day 15 and capecitabine 3500 mg/day, divided two, was administered for 7 consecutive days from day1 and day 15, and this was followed by a 7-day drug-free interval. Results: 35 eligible patients were enrolled in this study from Nov/2003 to Nov/2006. 14 women and 21 men: median age 51 ys, range 27–81. A total 106 courses were administered, and median number of courses per patient was three (range, 1–8). Intent-to-treatment analysis showed the one complete response (2.9%), 13 partial responses (37.1%), 9 stable disease (25.7%), 8 progressive disease (22.9%) and 4 non-evaluable patients (11.4%). The overall response rate was 40% (95% CI: 23.5–56.5). Grade 3–4 toxicities were: neutropenia 8 (22.8%), nausea/vomiting 2 (5.7%), stomatitis 1 (2.9%), ischemic colitis 1 (2.9%), anemia 3 (8.6%), diarrhea 2 (5.7%), alopecia 3 (8.6%). Treatment related death was shown at one patient due to pneumonia. Dose intensity of irinotecan and capecitabine was 94% and 93%, respectively. Median time to progression was 4 months (range, 0.5 - 11 months), median survival duration was 8.5 months (range, 0.5 - 45 months), and median response duration was 2.5 months (range, 0.5 - 9 months). Conclusions: We suggest that irinotecan and high dose capecitabine combination chemotherapy is the tolerable regimen to advanced or metastastic gastric cancer with promising activity.

No significant financial relationships to disclose.

Characterization of a recombinant molecule covalently indistinguishable from human cerebroside-sulfate activator protein (CSAct or Saposin B)

Humans deficient in the cerebroside-sulfate activator protein (CSAct or Saposin B) are unable to catabolize sulfatide and other glycosphingolipids leading to their accumulation and neurodegenerative disease. Clinically this usually manifests as a form of metachromatic leukodystrophy (MLD). CSAct is a small water-soluble glycoprotein that apparently functions in the lysosome to solubilize sulfatide and other lipids enabling their interaction with soluble lysosomal hydrolases. CSAct activity can be measured in vitro by assay of its ability to activate sulfatide-sulfate hydrolysis by arylsulfatase A or ex vivo by its ability to functionally complement CSAct deficient fibroblast cell lines derived from MLD patients. A recombinant form of CSAct has been expressed in E. coli and processed in vitro to a form covalently indistinguishable from deglycosylated human CSAct isolated from human urine. Size-exclusion chromatography in combination with multi-angle laser-light scattering (SEC-MALLS) measurements demonstrate that both native and recombinant forms of the molecule behave as a dimer in the pH range 7.0-4.5. The CSAct activity assay showed that both recombinant and deglycosylated human urine CSAct efficiently activated sulfatide sulfate hydrolysis and provided functional complementation of CSAct-deficient cells. However, a D21N mutant form of recombinant CSAct could not functionally complement these cells despite full activity in the in vitro assay. It is concluded that while glycosylation is unnecessary for in vitro and ex vivo activity of CSAct, modification of the native N21 is necessary to prevent loss of ex vivo activity, possibly via protection from degradation.

Pathogenicity and antigenicity of a new influenza A (H5N1) virus isolated from duck meat

Avian influenza A viruses are the ancestral origin of all human influenza viruses. The outbreak of highly pathogenic (HP) avian H5N1 in Hong Kong in 1997 highlighted the potential of these viruses to infect and cause severe disease in humans. Since 1999, HP H5N1 viruses were isolated several times from domestic poultry in Asia. In 2001, a HP H5N1 virus, A/Duck/Anyang/AVL-1/2001 (Dk/Anyang), was isolated from imported frozen duck meat in Korea. Because of this novel source of HP H5N1 virus isolation, concerns were raised about the potential for human exposure and infection; we therefore compared the Dk/Anyang virus with HP H5N1 viruses isolated from humans in 1997 in terms of antigenicity and pathogenicity for mammals. At high doses, Dk/Anyang virus caused up to 50% mortality in BALB/c mice, was isolated from the brains and lymphoid organs of mice, and caused lymphopenia. Overall Dk/Anyang virus was substantially less pathogenic for mice than the H5N1 virus isolated from a fatal human case in 1997. Likewise, Dk/Anyang virus was apathogenic for ferrets. Dk/Anyang virus was antigenically distinguishable by hemagglutination-inhibition (HI) assay from human H5N1 viruses isolated in 1997 and avian H5N1 viruses isolated in 2001 in Hong Kong. Nevertheless, prior infection with Dk/Anyang virus protected mice from death after secondary infection with HP human H5N1 viruses. These results indicate that compared with HP human H5N1 viruses, Dk/Anyang virus is substantially less pathogenic for mammalian species. Nevertheless, the novel source of isolation of this avian H5N1 virus must be considered when evaluating the potential risk to public health.

Rhodococcus equi pneumonia in a heart transplant recipient in Korea, with emphasis on microbial diagnosis

Rhodococcus equi is an opportunistic pathogen that usually causes infection in immunocompromised hosts. A heart transplant recipient who had been treated with amphotericin B for pulmonary aspergillosis showed newly developed multiple nodules with a central necrotic area in the right lower lobes. Cultures of several blood samples and an aspirate of the lung nodule yielded a Gram-positive coccobacillary bacterium, which was initially reported as a Corynebacterium species, but was later identified as R. equi by API CORYNE (bioMerieux SA, Marcy l'Etoile, France) and by demonstrating the production of 'equi factor'. The identification was subsequently confirmed by an R. equi-specific polymerase chain reaction (PCR). The patient was successfully treated with ciprofloxacin and azithromycin for 14 weeks. This is the first documented case of R. equi infection in Korea. There is a possibility of underestimation of R. equi infections due to the misidentification of the organism as a contaminating diphtheroid. Because R. equi will not respond to the conventional empirical therapy, the microbiology laboratory should identify R. equi in a timely manner. R. equi-specific PCR will be a useful confirmatory test in human infection.

Phylogenetic analysis of reverse transcriptase in antiretroviral drug-naive Korean HIV type 1 patients

To study whether genotypic antiretroviral resistance testing (GART) is needed to guide initial antiretroviral therapy in Korea, we determined partial pol sequences in peripheral blood mononuclear cells (PBMCs) obtained from 29 antiretroviral drug-naive HIV-1 patients. Phylogenetic analysis revealed four subtypes: B (23 patients), D (1 patient), recombinant strain (2 patients), and "untyped" (3 patients). Eighteen (78.3%) of the 23 subtype B isolates formed a distinct monophyletic cluster. The average genetic distances of 23 subtype B compared with reference strain HXB2 were 2.7% (range, 1.5-4.6%). Only one patient harbored variant virus containing a V179D mutation causing resistance to efavirenz. These data derived from therapy-naive patients suggest that potential use of primary resistance testing to guide initial antiretroviral therapy should be considered in Korea. This is the first report on the molecular nature of HIV-1 RT in Korea.

Long-term intake of Korean red ginseng in HIV-1-infected patients: development of resistance mutation to zidovudine is delayed

We have observed that CD4+ T cell counts in human immunodeficiency virus (HIV)-1-infected patients treated with only Korean red ginseng (KRG) are maintained or even increased for a prolonged period. In the present study, we investigated whether the development of resistance mutations in reverse transcriptase (RT) to zidovudine (ZDV) is delayed by combined therapy with KRG and ZDV. Nested polymerase chain reaction (PCR) and direct sequencing methods were used to define RT codons 41, 67, 70, 210, 215 and 219 of the HIV-1 pol gene in DNA from peripheral blood mononuclear cells (PBMC) samples from 18 patients. Nine of these eighteen patients were in the KRG group and had been treated with KRG for 60 +/- 15 months (range: 38-82) and ZDV, and nine were in the control group and had been treated with ZDV only. The patients in the KRG group had been treated with ZDV for 75 +/- 24 months, and CD4+ T cell counts were maintained from 239 +/- 85 to 234 +/- 187 microliters-1 (P > 0.05) during the study period, whereas the patients in the control group had been treated with ZDV for 51 +/- 31 months, and their CD4+ T cell counts decreased from 272 +/- 97 to 146 +/- 154 microliters-1 (P < 0.01). In samples within 24 months of ZDV therapy, the overall incidence of 6 resistance mutations to ZDV was 4.2% and 47% in the KRG and control group (P < 0.01), respectively. In samples after 24 months of therapy, the incidence was 21.7% and 56.3% in the KRG and control group (P < 0.01), respectively. These data suggest that the maintenance of CD4+ T cell counts by ZDV and KRG-intake for a prolonged period might be indirectly associated with delayed development of resistance to ZDV by KRG-intake.

Treatment compliance in the trajectory of treatment progress among offenders

Research on drug treatment process has been limited, with most studies centering on individual and program factors associated with successful treatment completion. Recent literature has begun highlighting the salience of treatment engagement in reducing drug dependence among criminal offenders. This study descriptively analyzes incidents of treatment noncompliance identified in monthly progress reports for 150 criminal justice-mandated clients in residential treatment. We identify seven problem types and seven dimensions of noncompliance in the trajectory of treatment engagement. The latter are prevalence, frequency, types, specialization, temporal distribution, paths, and correlates. It is found that incidents of rule violations are common among criminal justice participants of residential treatment. Although for most clients these troubles do not appear to evolve into serious obstacles to recovery, a few clients with a high frequency of noncompliant behavior never engage in treatment. Clinical implications for improving treatment engagement and retention are discussed.

In vivo antioxidant effect of green tea

OBJECTIVE

The object of this study was to investigate the in vivo antioxidant effect of green tea and dosage effect of green tea on antioxidant effect.

DESIGN

We tested 10 healthy subjects (aged 23-25 y, five women and five men) with overnight fasting. The total antioxidant capacity of plasma was measured at baseline and 60 min and 120 min after ingestion of 150 ml green tea. Green tea was prepared by infusing 2.5 g of dried green tea leaves for 2 min at 80 degrees C in 150 ml of water. In the second week, they took 300 ml of tea (5.0 g of green tea leaves) and, in the third week, 450 ml of tea (7.5 g of green tea leaves). The total antioxidant capacities of plasma were determined with a Total Antioxidant Kit (Randox Laboratories Ltd, UK) using a Cobas Mira analyser (Roche Diagnostic Systems Inc., Switzerland). The mean intra-assay coefficient of variation was 1.2%.

RESULTS

The total antioxidant capacity of plasma increased by 1.1% at 60 min and 2.1% at 120 min over baseline value in subjects consuming 150 ml of green tea, which was statistically not significant. However, total antioxidant capacity of plasma after consuming 300 ml of green tea showed a significant increase of 7.0% after 60 min and 6.2% after 120 min (P<0.0001), and after consuming 450 ml 12.0% after 60 min and 12.7% after 120 min over baseline value (P<0.0001).

CONCLUSIONS

Total antioxidant capacity of plasma was significantly increased after taking green tea in amounts of 300 and 450 ml. A positive increment according to green tea dosage was also observed.

SPONSORSHIP

This work was funded by the Pacific Corporation (Korea).

Structural abnormalities of autosomal chromosomes in the male partner do not influence fertilization and early development of embryos after intracytoplasmic sperm injection

The objective of this study was to determine whether or not abnormalities in the autosomal structure of the male partner have any influence on fertilization and early embryo development after intracytoplasmic sperm injection (ICSI). Thirty-seven couples in whom the male partners were examined by the same andrologist were included in this study. Six couples (group I) in whom the male partner possessed autosomal structural abnormality underwent seven ICSI cycles. As a control group, 31 couples (group II) in which the male partner was karyotypically normal underwent 41 ICSI cycles. Although the normal fertilization rates seen in group I were significantly higher than those in group II (P < 0.05), there was no significant difference in the cleavage rates between the two groups. We did not perform the analysis of the female partner's chromosomes, but we surmise that structural autosomal abnormalities in the male partner do not adversely influence fertilization at ICSI and early development of embryos.

Assessment of an epoxy-fixed pericardial patch with or without ionically bound heparin in a canine model

In this study, an epoxy-fixed porcine pericardial patch with or without ionically bound heparin was evaluated in a canine model as an alternative to the glutaraldehyde-fixed biological patch for clinical applications. To evaluate the effectiveness of this epoxy-fixed patch, a composite membrane composed of: an epoxy-fixed porcine patch with ionically bound heparin; a glutaraldehyde-fixed porcine patch with ionically bound heparin; an ePTFE polymeric patch; a polyester polymeric patch; an epoxy-fixed porcine patch without ionically bound heparin; and a glutaraldehyde-fixed porcine patch without ionically bound heparin was made. This membrane was assessed orthopically in a canine model. The early results (1 approximately 4 weeks post implant) revealed that the biological patches with ionically bound heparin had the mildest tissue reactions (inflammatory reaction, fibrosis, and adhesion) among all the test samples. However, by 12 weeks postoperatively, all the test samples had mild to severe tissue reactions. The order of tissue reactions with increasing severity was: the biological patches with ionically bound heparin, the biological patches without ionically bound heparin, and the polymeric patches. The results suggest that heparin may be used to reduce adhesion. Additionally, the epoxy-fixed tissue caused a relatively lower degree of inflammatory reaction than the glutaraldehyde-fixed tissue.