Association between obesity and cancer risk in HIV-infected Asians

INTRODUCTION

This study aimed to investigate the association between obesity and cancer risk as well as site-specific cancer risks in adults with HIV using a nationwide health screening database in Korea.

METHODS

Of the 16,671 adults with a new diagnosis of HIV from 2004 to 2020, 456 incident cancer cases and 1,814 individually matched controls by sex, year of birth, year of HIV diagnosis, and follow-up duration (1:4 ratio) were included in this nested case-control study. The association between obesity (body mass index ≥25 kg/m 2 ) and cancer risks was estimated and presented as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of the 456 cancer incident cases, there were 146 AIDS-defining cancer cases and 310 non-AIDS-defining cancer cases. Compared with non-obese adults with HIV, obese adults with HIV were at higher risk of non-AIDS-defining cancer (OR = 1.478, 95% CI = 1.118-1.955). Otherwise, the overall risk of AIDS-defining cancer (OR = 0.816, 95% CI = 0.520-1.279) and each type of AIDS-defining cancer (Kaposi sarcoma and non-Hodgkin's lymphoma) were not high in obese adults with HIV. Of the specific types of non-AIDS-defining cancers, obesity was associated with an increased risk of colorectal cancer (OR = 3.090, 95% CI = 1.110-8.604) and liver, bile duct, and pancreatic cancers (OR = 2.532, 95% CI = 1.141-5.617).

CONCLUSIONS

Obesity, which is one of the important health concerns in HIV management, was associated with an increased risk of non-AIDS-defining cancer but not AIDS-defining cancer.

Prevention of Cytomegalovirus Infection in Solid Organ Transplant Recipients: Guidelines by the Korean Society of Infectious Diseases and the Korean Society for Transplantation

Cytomegalovirus (CMV) is the most important opportunistic viral pathogen in solid organ transplant (SOT) recipients. The Korean guideline for the prevention of CMV infection in SOT recipients was developed jointly by the Korean Society for Infectious Diseases and the Korean Society of Transplantation. CMV serostatus of both donors and recipients should be screened before transplantation to best assess the risk of CMV infection after SOT. Seronegative recipients receiving organs from seropositive donors face the highest risk, followed by seropositive recipients. Either antiviral prophylaxis or preemptive therapy can be used to prevent CMV infection. While both strategies have been demonstrated to prevent CMV infection post-transplant, each has its own advantages and disadvantages. CMV serostatus, transplant organ, other risk factors, and practical issues should be considered for the selection of preventive measures. There is no universal viral load threshold to guide treatment in preemptive therapy. Each institution should define and validate its own threshold. Valganciclovir is the favored agent for both prophylaxis and preemptive therapy. The evaluation of CMV-specific cell-mediated immunity and the monitoring of viral load kinetics are gaining interest, but there was insufficient evidence to issue recommendations. Specific considerations on pediatric transplant recipients are included.

Nutritional index in relation to prognosis of endometrial cancer

Objective: Evaluate the prognostic value of the prognostic nutritional index (PNI) in patients with endometrial cancer (EC). Method: Laboratory and clinicopathological data from 370 patients who were diagnosed with EC between January 2010 and December 2021 were reviewed. The PNI was analyzed for correlations with recurrence and survival. The receiver operating characteristic curves were generated for the PNI. Optimal cut-off values were determined as the points at which the Youden index (sensitivity + specificity - 1) was maximal. Based on the results of the ROC curve analysis, the patients were grouped into high and low PNI groups. Differences in the clinicopathological characteristics between patients with high and low PNI were compared between the two groups. The effects of the prognostic factors were analyzed using univariate and multivariate Cox proportional hazards model. Results: The optimal cutoff value of the PNI was 52.74 for DFS (area under the curve: 0.817; 95% CI: 0.738-0.858, p <0.001). Significantly more patients in the low PNI group experienced recurrence (30.6% vs. 5.2%, p <0.001) and cancer-related death (17.8% vs. 2.8%, p <0.001). In multivariate analysis, PNI were independent prognostic factors for both DFS and overall survival OS. Conclusion: Low PNI was significantly associated with worse clinical outcomes in patients with EC. Our findings demonstrate that the PNI may be clinically reliable and useful as a prognostic marker for patients with EC. Further large-scale prospective studies are needed to confirm our findings.

Is robotic surgery beneficial for the treatment of endometrial cancer? A comparison with conventional laparoscopic surgery

Objective: The objective of this study was to compare the oncologic outcomes between those who underwent robotic surgery or conventional laparoscopic surgery for endometrial cancer. Method: We performed a retrospective review of patients from a single institution who underwent either laparoscopic or robotic surgery for the treatment of endometrial cancer between January 2010 and December 2020. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 268 patients included in this study, 95 underwent robotic surgery (35.4%) and 173 underwent laparoscopic surgery (64.6%). The median follow-up durations were 51 and 59 months for the robotic surgery and laparoscopic surgery groups, respectively (p = 0.085). The recurrence rate did not differ significantly between the two groups. (p = 0.371). Disease-free survival (p = 0.721) and overall survival (p = 0.453) were similar between the two groups. In both univariate and multivariate analyses, the type of surgery was not related to disease-free survival. The median total cost per admission was significantly higher for RS than for LS (12,123 vs. 6,884 USD, p < 0.0001). Conclusion: With consistently greater costs and similar survival outcomes, robotic systems have few advantages compared with laparoscopy.

Assessment of Disease Burden and Immunization Rates for Vaccine-Preventable Diseases in People Living with HIV: The Korea HIV/AIDS Cohort Study

BACKGROUND

Prophylactic immunization is important for human immunodeficiency virus (HIV)-infected patients; however, there are insufficient data on the burden of vaccine-preventable diseases (VPDs), vaccination rates, and factors influencing vaccination.

MATERIALS AND METHODS

The incidence and prevalence of VPDs in HIV-infected patients between 2006 and 2017 were estimated using the Korean HIV/acquired immune deficiency syndrome (AIDS) cohort database. In addition, we evaluated the vaccination rates and influencing factors for vaccination in HIV-infected patients through multilevel analysis of clinico-epidemiological factors, immune status, and psychological status. A questionnaire survey was conducted among experts to determine whether they recommend vaccination for HIV-infected patients.

RESULTS

The incidence rates of hepatitis B virus (HBV) infection, herpes zoster, and anogenital warts were 1.74, 7.38, and 10.85 per 1,000 person-years, respectively. The prevalence of HBV infection and anogenital warts at enrollment was 4.8% and 8.6%, respectively, which increased to 5.3% and 12.0%, respectively, by 2017. In HIV-infected patients, HBV (21.7% in 2008, 56.3% in 2013, and 75.4% in 2017) and pneumococcal vaccination rates (3.0% in 2015, 7.6% in 2016, and 9.6% in 2017) increased annually, whereas the influenza vaccination rate remained similar by season (32.7 - 35.6%). In the multilevel analysis, peak HIV viral load (≥50 copies/mL: odds ratio [OR] = 0.64, 95% confidence interval [CI]: 0.44 - 0.93; reference, <50 copies/mL) was an influencing factor for pneumococcal vaccination, while nadir CD4 T-cell counts (200 - 350 cells/mm3: OR = 0.54, 95% CI: 0.38 - 0.76; <200 cells/mm3: OR = 0.89, 95% CI: 0.62 - 1.28; reference, ≥350 cells/mm3) was an influencing factor for HBV vaccination. Influenza vaccination was associated with male sex (OR = 1.94) and the number of antiretroviral therapy (ART) regimen change (OR = 1.16), but was not significantly associated with HIV viral load or CD4 T-cell counts. Most experts responded that they administer hepatitis A virus, HBV, pneumococcal, and influenza vaccines routinely, but not human papillomavirus (12.9%) or herpes zoster vaccines (27.1%).

CONCLUSION

The burden of vaccine-preventable diseases was quite high in HIV-infected patients. Nadir CD4 T-cell counts, peak HIV viral loads, and the number of ART regimen change are significant factors related to vaccination. Considering the low vaccination rates for VPDs, there was a discordance between experts' opinions and real clinical practice in the medical field.

Risk of lymphadenopathy from SARS-CoV-2 vaccination in Korea: a self-controlled case series analysis

OBJECTIVES

To assess the risk of lymphadenopathy following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination.

METHODS

A self-controlled case series design was used to determine whether the risk of lymphadenopathy was higher in the 1-day to 42-day risk interval after coronavirus disease 2019 (COVID-19) vaccination compared to the control period. In addition, subgroup analyses were conducted according to baseline characteristics, time since vaccination, and sensitivity analyses adjusted for the length of the risk interval.

RESULTS

The risk of developing lymphadenopathy in the risk interval (1-42 days) after COVID-19 vaccination compared to the control period was significantly increased, with a relative incidence (RI) of 1.17 (95% confidence interval [CI], 1.17 to 1.18) when the first, second, and third doses were combined. The RI was greater on the day of vaccination (1.47; 95% CI, 1.44 to 1.50). In subgroup analyses by baseline characteristics, a significantly increased risk or trend toward increased risk was observed in most subgroups except for those aged 70 years and older, with a significant increase in risk in younger individuals, those with a Charlson's comorbidity index <5, and those who received mRNA vaccines (mRNA-1273>BNT162b2). Within the 1-day to 42-day post-dose risk period, the relative risk was highest during the 1-day to 7-day post-dose period (1.59; 95% CI, 1.57 to 1.60) compared to the control period, and then the risk declined. In the sensitivity analysis, we found that the longer the risk window, the smaller the RI.

CONCLUSIONS

SARS-CoV-2 vaccination is associated with a statistically significant increase in the risk of lymphadenopathy, and this risk was observed only with mRNA vaccines.

High-dose (60 Gy) intensity-modulated radiotherapy with concurrent weekly cisplatin followed by intracavitary radiation in locally advanced cervical cancer: A phase II prospective clinical trial

OBJECTIVE

Radiotherapy dose-escalation using intensity-modulated radiotherapy (IMRT) has been necessary to improve treatment results in cervical cancer.

METHODS

This was a phase II prospective clinical trial. 88 patients with FIGO II-IVa cervical cancer were enrolled in a single center. They received high-dose (60 Gy) IMRT with weekly cisplatin to the primary tumor and clinically positive nodes followed by intracavitary radiation. The primary endpoint was 30-month PFS rate (Target; 82%, an increase of 20% compared to GOG 120 trial using standard-dose radiotherapy). Secondary endpoints were tumor response, toxicity, recurrence, distant metastasis, and overall survival.

RESULTS

Progression-free survival rate at 30 months was 82.8%. Overall survival, locoregional recurrence, distant metastasis, and para-aortic recurrence rates at 30 months were 93.6%, 8.2%, 9.2%, and 2.4%, respectively. Forty-five (51.1%) of 88 patients achieved downstaging on MRI during radiotherapy and 80 (90.9%) patients had clinically complete response at three months after high-dose IMRT and intracavitary radiotherapy. The 30-month recurrence-free survival (92.9% vs. 73.1%, P = 0.009) and overall survival (100% vs. 87.0%, P = 0.006) were significantly higher in the downstaged group than in the non-downstaged group during radiotherapy. Grade 3 or higher hematologic toxicity was found in 11 (12.5%) patients and grade 3 or higher non-hematologic toxicity was found in 3 (3.4%) patients. Fourteen had chronic urinary (8.0%), intestinal (5.7%) toxicity, pelvic insufficiency fracture (2.3%) or vesicovaginal fistula (2.3%).

CONCLUSION

High-dose (60 Gy) IMRT with concurrent weekly cisplatin in locally advanced cervical cancer yielded favorable progression-free survival outcome. Tumor response during radiotherapy can be a significant prognostic factor for PFS.

CLINICAL TRIAL INFORMATION

This prospective trial is registered at ClinicalTrials.gov Identifier: NCT02993653.

Recommendations for SARS-CoV-2 testing and organ procurement from deceased donors in the Republic of Korea

We present a summary of the evidence on testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and organ procurement from deceased donors and provide recommendations based on current clinical data and the guidelines from major transplant organizations. Because of the limited historical experience with coronavirus disease 2019 (COVID-19), certain recommendations in this document are based on theoretical rationales rather than clinical data. The recommendations in this manuscript may be subject to revision as subsequent clinical studies provide definitive evidence regarding COVID-19 in organ procurement.

Effect of characteristics on the clinical course at the initiation of treatment for human immunodeficiency virus infection using dimensionality reduction

The beginning of human immunodeficiency virus (HIV) infection treatment depends on various factors, which are significantly correlated with the initial CD4 cell number. However, a covariate correlation between these factors may not reflect the correct outcome variable. Thus, we evaluated the effects of a combination of fixed factors (reduced dimensions), which determine when to start treatment for the first time, on short-term outcome, long-term outcome, and survival, considering correlations between factors. Multiple correspondence analysis was performed on variables obtained from 925 patients who participated in a Korean HIV/acquired immunodeficiency syndrome cohort study (2006-2017). Five reduced dimension groups were derived according to clinical data, viral load, CD4 cell count at diagnosis, initial antiretroviral therapy, and others. The dimension group with high initial viral loads (55,000 copies/mL) and low CD4 cell counts (< 200 cells/mm³) should start treatment promptly after diagnosis. Groups with high initial CD4 cell counts (> 350 cells/mm³) that did not require immediate treatment according to previous guidelines had a higher failure rate for long-term relative CD4 recovery. Our results highlight the importance of early diagnosis and treatment to positively influence long-term disease outcomes, even if the initial immune status is poor, given the patient's combination of early diagnostic symptoms.

Rate of and Risk Factors for Loss to Follow Up in HIV-Infected Patients in Korea: The Korea HIV/AIDS Cohort Study

BACKGROUND

Owing to antiretroviral therapy (ART), acquired immune deficiency syndrome (AIDS)-related mortality has significantly decreased. Retaining in care is an essential step for human immunodeficiency virus (HIV) care cascade. This study investigated the incidence of and risk factors for loss to follow-up (LTFU) in Korean people living with HIV (PLWH).

MATERIALS AND METHODS

Data from the Korea HIV/AIDS cohort study (including prospective interval cohort and retrospective clinical cohort) were analyzed. LTFU was defined as not visiting the clinic for more than 1 year. Risk factors for LTFU were identified using the Cox regression hazard model.

RESULTS

The study enrolled 3,172 adult HIV patients (median age, 36 years; male 92.97%). The median CD4 T cell count at enrollment was 234 cells/mm³ (interquartile range [IQR]: 85 - 373) and the median viral load at enrollment was 56,100 copies/mL (IQR: 15,000 - 203,992). The total follow-up duration was 16,487 person-years, and the overall incidence rate of LTFU was 85/1,000 person-years. In the multivariable Cox regression model, subjects on ART were less likely to have LTFU than subjects not on ART (hazard ratio [HR] = 0.253, 95% confidence interval [CI]: 0.220-0.291, P <0.0001). Among PLWH on ART, female sex (HR = 0.752, 95% CI: 0.582-0.971, P = 0.0291) and older age (>50: HR = 0.732, 95% CI: 0.602 - 0.890; 41 - 50: HR = 0.634, 95% CI: 0.530 - 0.750; 31 - 40: HR = 0.724, 95% CI: 0.618 - 0.847; ≤30: reference, P <0.0001) were associated with high rate of retention in care. The viral load at ART initiation ≥1,000,001 (HR = 1.545, 95% CI: 1.126 - 2.121, ≤10,000: reference) was associated with a higher rate of LTFU.

CONCLUSION

Young and male PLWH may have a higher rate of LTFU, and an increased rate of LTFU may induce virologic failure.

Robot-assisted versus conventional laparoscopic radical hysterectomy in cervical cancer stage IB1

Objective: The aim of this study was to compare survival outcomes of robot-assisted laparoscopic radical hysterectomy (RRH) and conventional laparoscopic radical hysterectomy (LRH) in cervical cancer stage IB1. Method: This is a retrospective study of patients with cervical cancer stage IB1 who surgically treated by either RRH or LRH. Oncologic outcomes of the patients were compared according to surgical approach. Results: In total, 66 and 29 patients were assigned to LRH and RRH groups. All patients had stage IB1 disease (FIGO 2018). Intermediate risk factors (tumor size, LVSI, and deep stromal invasion), proportion of patients receiving adjuvant therapy (30.3% vs. 13.8%, p = 0.09), and median follow-up time (LRH, 61 months; RRH, 50 months; p=0.085) did not differ significantly between the two groups. The recurrence rate was higher in the LRH group; however, there was no significant difference between the two groups (p=0.250). DFS (55.4 vs 48.2 months, p = 0.250), and OS (61.2 vs 50.0 months, p = 0.287) were similar between the LRH and RRH groups. Conclusion: In patients with a tumor size < 2 cm, the recurrence rate was lower in RRH group; however, there was no significant difference. Further large-scale RCTs and clinical studies are required to provide relevant data.

Nationwide survey of infection prevention protocols in solid organ transplantation in South Korea

Background

Infections are a major cause of morbidity, graft failure, and mortality in solid organ transplant recipients. Preventive measures have greatly reduced the burden of posttransplant infections. However, little is known about the practice patterns of infection prevention in South Korea.

Methods

A questionnaire-based cross-sectional survey was conducted. The questionnaire was developed by a multidisciplinary discussion. From the Korean Network for Organ Sharing data, a list of hospitals that performed kidney, liver, heart, and lung transplantations in 2019 was selected. We invited participants to respond to the questionnaire via email from January to March 2022.

Results

The response rates for each organ were as follows; 41% (31/76 hospitals) for kidney, 49% (25/51) for liver, 40% (8/20) for heart, and 89% (8/9) for lung transplantations. The median duration of antibacterial prophylaxis after transplant ranged from 5 to 7 days. Prophylaxis was commonly applied in cytomegalovirus (CMV) D+/R– recipients. For non-lung CMV R+ recipients, a preemptive strategy was the most common method. The duration of viral load monitoring for preemptive or hybrid strategies varied. All lung transplant programs used mold-active antifungal agents for a median of 6 months. An interferon-gamma release assay was most commonly used to screen for latent tuberculosis infections.

Conclusions

The infection prevention protocols in most transplant programs in Korea were generally in accordance with the guidelines. However, some variability was observed regarding antibacterial prophylaxis and CMV prevention. Our results provide useful insights into practice patterns and will assist in the development of national guidelines.

Mortality and Causes of Death among Individuals Diagnosed with Human Immunodeficiency Virus in Korea, 2004-2018: An Analysis of a Nationwide Population-Based Claims Database

The mortality rate and causes of death among individuals diagnosed with human immunodeficiency virus (HIV) infection in Korea were described and compared to those of the general population of Korea using a nationwide population-based claims database. We included 13,919 individuals aged 20-79 years newly diagnosed with HIV between 2004 and 2018. The patients' vital status and cause of death were linked until 31 December 2019. Standardized mortality ratios (SMRs) for all-cause death and specific causes of death were calculated. By the end of 2019, 1669 (12.0%) of the 13,919 HIV-infected participants had died. The survival probabilities of HIV-infected individuals at 1, 5, 10, and 15 years after diagnosis in Korea were 96.2%, 91.6%, 85.9%, and 79.6%, respectively. The main causes of death during the study period were acquired immunodeficiency syndrome (AIDS; 59.0%), non-AIDS-defining cancer (8.2%), suicide (7.4%), cardiovascular disease (4.9%), and liver disease (2.7%). The mortality rate of men and women infected with HIV was 5.60-fold (95% CI = 5.32-5.89) and 6.18-fold (95% CI = 5.30-7.09) that of men and women in the general population, respectively. After excluding deaths due to HIV, the mortality remained significantly higher, with an SMR of 2.16 (95% CI = 1.99-3.24) in men and 3.77 (95% CI = 3.06-4.48) in women. HIV-infected individuals had a higher overall mortality than the general population, with AIDS the leading cause of mortality. Additionally, mortality due to non-AIDS-related causes was higher in HIV-infected individuals.

Usefulness of Short-Term Imaging and Squamous Cell Carcinoma Antigen to Early Predict Response to Concurrent Chemoradiotherapy in Patients With Cervical Cancer

OBJECTIVE

The objective is to investigate the factors that can predict early treatment response in patients receiving concurrent chemoradiotherapy (CCRT) for cervical cancer.

METHODS

We assessed clinical factors and treatment response in patients who underwent CCRT for cervical cancer at four time points: initial, 2.5 weeks, 6 weeks after starting CCRT, and 3 months after completing CCRT. The final treatment response was determined by positron emission tomography-computed tomography (PET-CT) 3 months after completion of CCRT. Patients were divided into two groups according to the final treatment response: complete response (CR) group or non-CR group. And the early CCRT response prediction model was developed using stepwise multivariate logistic regression analysis.

RESULTS

Of the 62 patients who underwent CCRT for cervical cancer, 57 patients who completed all 4 time points examinations were included in the analyses and classified as CR (n = 32) and non-CR (n = 25) group. Tumor volume and serum squamous cell carcinoma antigen (SCC Ag) of the initial, 2.5 weeks, and 6 weeks after CCRT were significantly associated with the final treatment response. For the early treatment response prediction model, we selected patient age, tumor volume, and SCC Ag measured at initial and 2.5 weeks of CCRT as variables, and the equation of the final model was yielded. Using a cutoff of 0.433, this model had a sensitivity of 72.0%, a specificity of 84.4%, and a probability of 0.8225 (P < .0001).

CONCLUSION

Short-term (at 2.5 weeks after starting CCRT) measurements of tumor volume and serum SCC Ag were significant predictors of response to CCRT in patients with cervical cancer.

Adverse reactions and production of neutralizing anti-SARS-CoV-2 antibodies after ChAdOx1 COVID-19 vaccination: A cross-sectional study in a single center

Adverse events following vaccination with the ChAdOx1 COVID-19 vaccine may be associated with the titer of neutralizing antibodies (NAbs) against SARS-CoV-2. In this cross-sectional study, a total of 82 HCWs who received the ChAdOx1 COVID-19 vaccine and did not have previous COVID-19 history were enrolled during March 2021. Blood samples were collected from HCWs 3 weeks after the first and second doses of vaccine, and NAbs were estimated using two types of commercially available kits, the cPass™ SARS-CoV-2 NAbs Kit (Genscript Biotech, Piscataway, NJ, USA) and R-FIND SARS-CoV-2 NAbs ELISA (SG Medical, Seoul, Korea). Median percent signal inhibition of NAbs was significantly higher after the second than after the first dose of vaccine, as determined using both the Genscript (median 43.1[IQR 71.2] vs. 93.6[83.1], p = 0.004) and R-FIND (53.2[82.6] vs. 76.8 [90.6], p = 0.03) kits. The percent signal inhibition of NAbs after the second dose of vaccine was higher in HCWs with than without systemic adverse events after the second dose, as determined using both the Genscript (p = 0.03) and R-FIND (p = 0.07) kits. The two doses of the ChAdOx1 vaccine induced high value of NAbs 3 weeks after vaccination. Immune responses were stronger in HCWs with than without adverse reactions after the second dose of ChAdOx1 vaccine.

The Incidence and Risk Factors of Renal Insufficiency among Korean HIV infected Patients: The Korea HIV/AIDS Cohort Study

Renal insufficiency is one of the common issues in people living with human immunodeficiency virus (PLHIV). We studied the incidence and risk factors for renal insufficiency in male PLHIV using the Korea HIV/acquired immunodeficiency syndrome (AIDS) Cohort Study. Among the 830 enrolled patients, 32 (3.9%) cases of renal insufficiency occurred over 9576 patient-years of follow-up. The incidence of renal insufficiency in HIV-infected men in this study was 3.3 per 1000 patient-years. Diabetes mellitus, dyslipidemia, tenofovir or non-nucleoside reverse transcriptase inhibitor exposure for >1 year, and AIDS-defining illness were risk factors for renal insufficiency.

Comparison of Three Cardiovascular Risk Scores among HIV-Infected Patients in Korea: The Korea HIV/AIDS Cohort Study

Background

We investigated cardiovascular disease (CVD), risk factors for CVD, and applicability of the three known CVD risk equations in the Korean human immunodeficiency virus/ Acquired Immune Deficiency Syndrome (HIV/AIDS) cohort.

Materials and Methods

The study parcitipants were HIV-infected patients in a Korean HIV/AIDS cohort enrolled from 19 hospitals between 2006 and 2017. Data collected at entry to the cohort were analyzed. The 5-year CVD risk in each participant was calculated using three CVD risk equations: reduced CVD prediction model of HIV-specific data collection on adverse effects of anti-HIV drugs (R-DAD), Framingham general CVD risk score (FRS), and Korean Coronary Heart Disease Risk Score (KRS).

Results

CVD events were observed in 11 of 586 HIV-infected patients during a 5-year (median) follow-up period. The incidence of CVD was 4.11 per 1,000 person-years. Older age (64 vs. 41 years, P = 0.005) and diabetes mellitus (45.5% vs. 6.4%, P <0.001) were more frequent in patients with CVD. Using R-DAD, FRS, and KRS, 1.9%, 2.4%, and 0.7% of patients, respectively, were considered to have a very high risk (≥10%) of 5-year CVD. The discriminatory capacities of the three prediction models were good, with c-statistic values of 0.829 (P <0.001) for R-DAD, 0.824 (P <0.001) for FRS, and 0.850 (P = 0.001) for KRS.

Conclusion

The FRS, R-DAD, and KRS performed well in the Korean HIV/AIDS cohort. A larger cohort and a longer period of follow-up may be necessary to demonstrate the risk factors and develop an independent CVD risk prediction model specific to Korean patients with HIV.

Prognostic significance of histological grade in low-risk endometrial cancer

Objective: Investigate the risk factors for recurrence in patients with low-risk endometrial cancer. Method: A retrospective review was performed to identify patients who underwent primary surgical treatment for endometrial cancer from December 2009 to December 2020. Patients who met the following criteria were included in the study: (a) International Federation of Gynecology and Obstetrics stage IA, (b) endometrioid-type histology, (c) histological grade 1 or 2. Univariate and multivariate analyses using Cox proportional hazards model to evaluate effects of prognostic factors. Disease-free survival and overall survival were calculated using the Kaplan-Meier method. Results: A total of 171 patients with low-risk endometrial cancer were included in the study. Recurrence was detected in 9 patients. Histological grade was found to be independent risk factors for recurrence in women with low-risk endometrial cancer (OR 8.255, 95% confidence interval (CI) 1.585 - 42.981; p = 0.012). Conclusion: The results of this study suggest that grade 2 disease should be considered a significant prognostic factor for the recurrence of low-risk endometrial cancer.

Prognostic value of pretreatment systemic inflammatory markers in patients with stage I endometrial cancer

Objective: Evaluate the prognostic value of monocyte-lymphocyte ratio (MLR) in patients with stage I endometrial cancer. Method: Data from 225 patients with stage I endometrioid endometrial cancer who underwent surgical resection between January 2010 and December 2020 were reviewed. The receiver operating characteristic (ROC) curves were generated for the neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and MLR. Optimal cut-off values were determined as the points at which the Youden index (sensitivity + specificity - 1) was maximal. Based on the results of the ROC curve analysis, the patients were grouped into high MLR and low MLR groups. Recurrence rate, and disease-free survival were compared between the two groups. The prognostic factors were investigated using univariate and multivariate Cox proportional hazards model. Results: The optimal cut-off value of MLR was 0.220 (AUC, 0.835; p < 0.001). Significantly more patients in the high MLR group experienced recurrence (20.3% vs. 1.9%, p < 0.0001). In multivariate analysis, grade, depth of myometrial invasion, adjuvant RT, and high MLR were independent prognostic factors for disease-free survival. Conclusion: Elevated MLR was significantly associated poor clinical outcomes in patients with stage I endometrioid endometrial cancer. Our findings suggest that MLR may be clinically reliable and useful as an independent prognostic marker for patients with stage I endometrioid endometrial cancer.

Postoperative Adjuvant Chemoradiotherapy Versus Chemotherapy Alone for Stage III Endometrial Cancer: A Multicenter Retrospective Study

Introduction

We aimed to evaluate the efficacy and toxicity of the combination of 6 cycles of chemotherapy and radiation therapy compared with chemotherapy alone as postoperative adjuvant therapy for patients with stage III endometrial cancer.

Methods

This retrospective cohort study included patients with stage III endometrial cancer who received postoperative chemoradiotherapy or chemotherapy alone at 6 hospitals between January 2009 and December 2019. The progression-free survival (PFS) and overall survival (OS) for each treatment group were analyzed using the Kaplan–Meier method. We also assessed differences in toxicity profiles between the treatment groups.

Results

A total of 133 patients met the inclusion criteria. Of these, 80 patients (60.2%) received adjuvant chemoradiotherapy and 53 (39.8%) received chemotherapy alone. The PFS and OS did not differ significantly between the groups. For patients with stage IIIC endometrioid subtype, the chemoradiotherapy group had significantly longer PFS rate than did the chemotherapy alone group (log-rank test, P = .019), although there was no significant difference in the OS (log-rank test, P = .100). CRT was identified as a favorable prognostic factor for PFS in multivariate analysis (adjusted HR, .37; 95% CI, .16-.87; P = .022). Patients treated with chemoradiotherapy more frequently suffered from grade 4 neutropenia (73.8% vs 52.8%; P = .018) and grade 3 or worse thrombocytopenia (36.3% vs 9.4%; P = .001) compared with the chemotherapy alone group. There were no differences between the 2 treatment groups in the frequency of toxicity-related treatment discontinuation or dose reduction.

Conclusion

We confirmed that chemoradiotherapy yields longer progression-free survival than does chemotherapy alone for patients with stage IIIC endometrioid endometrial cancer, with an acceptable toxicity profile.

Oncologic safety of minimally invasive surgery in non-endometrioid endometrial cancer

OBJECTIVE

This study was aimed to compare the oncologic outcomes of patients with non-endometrioid endometrial cancer who underwent minimally invasive surgery with the outcomes of patients who underwent open surgery.

METHOD

This is a retrospective, multi-institutional study of patients with non-endometrioid endometrial cancer who were surgically staged by either minimally invasive surgery or open surgery. Oncologic outcomes of the patients were compared according to surgical approach.

RESULTS

113 patients met the inclusion and exclusion criteria. 57 underwent minimally invasive surgery and 56 underwent open surgery. Patients who underwent minimally invasive surgery had smaller tumors (median size, 3.3 vs. 5.2%, p = 0.0001) and a lower lymphovascular space invasion rate (29.8% vs. 48.2%, p = 0.045). In the overall population, the numbers and rate of recurrence were significantly higher in the open surgery group (p = 0.016). In multivariate analysis, disease stage and tumor size were associated with DFS in contrast to surgical procedure.

CONCLUSION

Minimally invasive surgery showed similar survival outcomes when compared to open surgery in non-endometrioid endometrial cancer patients, irrespective of disease stage. When minimally invasive surgery is managed by expert surgeons, non-endometrioid histological subtypes should not be considered a contraindication for minimally invasive surgery.

Functional profiles of Müllerian inhibiting substance/anti-Müllerian hormone (MIS/AMH) in primarily cultured endometrial cancer cells

Background: Müllerian inhibiting substance/anti-Müllerian hormone (MIS/AMH) inhibits proliferation of MIS/AMH receptor-expressing gynecologic tumors in vivo and in vitro, but the underlying mechanisms have not been fully defined. This study aimed to investigate the expression of MIS/AMH type II receptor (MIS/AMHRII) in endometrial cancer, to identify the mechanism of growth inhibition in MIS/AMH-treated endometrial cancer cells, and to evaluate the clinical significance of MIS/AMH as an effective targeted therapy for MIS/AMH receptor-expressing tumors.

Methods: We used tissue samples from 10 patients with total hysterectomy for endometrial cancer. To identify involved signaling pathways, we performed western blotting on apoptosis-, cell cycle-, Wnt signaling-, and autophagy-related proteins.

Results: MIS/AMHRII was highly expressed on the cell membrane of endometrial cancer tissues and primarily cultured endometrial cancer cells. We also found that MIS/AMH treatment reduced cell viability, induced cell cycle arrest, and increased apoptosis. MIS/AMH treatment induced upregulation of β-catenin-interacting protein (ICAT) and inhibition of the Dvl and Axin complex (IDAX) but downregulation of phospho-c-Jun in the Wnt signaling pathway.

Conclusions: MIS/AMH inhibits the growth of MIS/AMH receptor-expressing endometrial cancer cells through regulation of autophagy, apoptosis, and cell cycle pathways, as well as inhibition of Wnt signaling pathways. These data suggest that MIS/AMH functions as a tumor suppressor and may be an effective therapeutic agent in endometrial cancer.

Developing a Framework for Pandemic COVID-19 Vaccine Allocation: a Modified Delphi Consensus Study in Korea

BACKGROUND

This study presents a framework for determining the allocation and distribution of the limited amount of vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

METHODS

After analyzing the pandemic strategies of the major organizations and countries and with a literature review conducted by a core panel, a modified Delphi survey was administered to 13 experts in the fields of vaccination, infectious disease, and public health in the Republic of Korea. The following topics were discussed: 1) identifying the objectives of the vaccination strategy, 2) identifying allocation criteria, and 3) establishing a step-by-step vaccination framework and prioritization strategy based on the allocation criteria. Two rounds of surveys were conducted for each topic, with a structured questionnaire provided via e-mail in the first round. After analyzing the responses, a meeting with the experts was held to obtain consensus on how to prioritize the population groups.

RESULTS

The first objective of the vaccination strategy was maintenance of the integrity of the healthcare system and critical infrastructure, followed by reduction of morbidity and mortality and reduction of community transmission. In the initial phase, older adult residents in care homes, high-risk health and social care workers, and personal support workers who work in direct contact with coronavirus disease 2019 (COVID-19) patients would be prioritized. Expansion of vaccine supply would allow immunization of older adults not included in phase 1, followed by healthcare workers not previously included and individuals with comorbidities. Further widespread vaccine supply would ensure availability to the extended adult age groups (50-64 years old), critical workers outside the health sector, residents who cannot socially distance, and, eventually, the remaining populations.

CONCLUSION

This survey provides the much needed insight into the decision-making process for vaccine allocation at the national level. However, flexibility in adapting to strategies will be essential, as new information is constantly emerging.

EVALUATION OF INTERNAL EXPOSURE TO RADIOACTIVE AEROSOL GENERATED FROM PLASMA MELTING SYSTEM USING THE BIDAS CODE

The radioactive aerosol generated by the Nuclear Power Plant (NPP) decommissioning process can be inhaled by workers and deposited inside the human body, resulting in internal exposure. Because internal exposure, unlike external exposure, is difficult to measure directly, it is all the more necessary to assess the dose workers receive as a result of internal exposure. Precise assessment of the internal exposure necessitates actual measurements in the work environment such as the workers' respiration rate, kind of nuclide and amount of captured nuclide. However, in the event of difficulties in securing these measurements, the internal exposure dose can be estimated based upon the recommended values by the ICRP (International Commission on Radiological Protection) such as the intake fraction and particle size. In this study, 5 μm was selected as the particle size as recommended by the ICRP, and both heavy and light respiratory rates were used in the calculation. With respect to the nuclides contained in the radioactive aerosol and their concentrations, the data captured for the aerosol in the melting facility on the Kozloduy NPP premises in Bulgaria were applied to estimate workers' internal exposure. As a result, each worker was found not to have received more than 20 mSv/yr, which is the maximum annual permissible dose for workers.

Role of surgery and hyperthermic intraperitoneal chemotherapy in ovarian cancer

Ovarian cancer is one of the deadliest gynaecological malignancies and tends to be diagnosed at an advanced stage. Similar to many malignancies, surgery plays a critical role in many aspects of ovarian cancer management. Hyperthermic intraperitoneal chemotherapy (HIPEC) involves the induction of hyperthermia and delivery of intraperitoneal chemotherapy directly into the peritoneal cavity. Combined with cytoreductive surgery, HIPEC is an emerging treatment modality for ovarian cancer. Ovarian cancer survival outcomes can be improved by treatment with surgery and HIPEC in selected patients. Thus, this study aimed to review the current role of surgery and HIPEC in epithelial ovarian cancer. Evidence from the monumental and recent literature will be introduced.

•

Surgery plays a critical role in many aspects of ovarian cancer management.

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Combined with cytoreductive surgery, HIPEC is an emerging modality for ovarian cancer.

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Improvement of survival outcomes is expected by applying individualised surgery and HIPEC for each ovarian cancer patient.

Neutralization of Zika virus by E protein domain III-Specific human monoclonal antibody

Zika virus (ZIKV) infection in both infants and adults is associated with neurological complications including, but not limited to, microcephaly and Guillain-Barre syndrome. Antibody therapy can be effective against virus infection. We isolated ZIKV envelope domain III-specific neutralizing antibodies (nAbs) from two convalescent patients with ZIKV infection. One antibody, 2F-8, exhibited potent in vitro neutralizing activity against Asian and American strains of ZIKV. To prevent FcγR-mediated antibody-dependent enhancement, we prepared IgG₁ with LALA variation. A single dose of 2F-8 in the context of IgG₁ or IgG₁-LALA prior to or post lethal ZIKV challenge conferred complete protection in mice.

Stereotypic neutralizing VH antibodies against SARS-CoV-2 spike protein receptor binding domain in patients with COVID-19 and healthy individuals

Stereotypic antibodies (Abs) are produced in healthy individuals by preexisting naïve B cells that have not undergone somatic hypermutation or class switching. Kim et al. have identified stereotypic neutralizing Abs (nAbs) against SARS-CoV-2 spike protein receptor binding domain (RBD) in healthy individuals and patients with COVID-19. They detected RBD-specific stereotypic variable heavy chain (V_H) Ab clonotypes composed of Ig heavy variable 3-53 (IGHV3-53) or IGHV3-66 and Ig heavy joining 6 (IGHJ6) genes in 13 of 17 patients with COVID-19. One stereotypic nAb could inhibit in vitro replication of a clinical isolate of SARS-CoV-2. These V_H clonotypes were also found in 6 of 10 healthy individuals with no evidence of exposure to SARS-CoV-2, and together, these findings provide evidence of the presence of preexisting nAbs to SARS-CoV-2.

Stereotypic antibody clonotypes exist in healthy individuals and may provide protective immunity against viral infections by neutralization. We observed that 13 of 17 patients with COVID-19 had stereotypic variable heavy chain (V_H) antibody clonotypes directed against the receptor binding domain (RBD) of SARS-CoV-2 spike protein. These antibody clonotypes were composed of immunoglobulin heavy variable 3-53 (IGHV3-53) or IGHV3-66 and immunoglobulin heavy joining 6 (IGHJ6) genes. These clonotypes included IgM, IgG3, IgG1, IgA1, IgG2, and IgA2 subtypes and had minimal somatic mutations, which suggested swift class switching after SARS-CoV-2 infection. The different IGHV chains were paired with diverse light chains resulting in binding to the RBD of SARS-CoV-2 spike protein. Human antibodies specific for the RBD can neutralize SARS-CoV-2 by inhibiting entry into host cells. We observed that one of these stereotypic neutralizing antibodies could inhibit viral replication in vitro using a clinical isolate of SARS-CoV-2. We also found that these V_H clonotypes existed in 6 of 10 healthy individuals, with IgM isotypes predominating. These findings suggest that stereotypic clonotypes can develop de novo from naïve B cells and not from memory B cells established from prior exposure to similar viruses. The expeditious and stereotypic expansion of these clonotypes may have occurred in patients infected with SARS-CoV-2 because they were already present.

Minimally invasive surgery for patients with advanced stage endometrial cancer

Objective: Compare the oncologic outcomes of patients with advanced stage endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery. Methods: Data from 138 patients with advanced stage endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 138 patients included in this study, 72 underwent open surgery (52.2%) and 66 underwent MIS (47.8%). In patients with advanced-stage endometrial cancer, the recurrence rate was significantly higher among those who underwent open surgery (43.1% vs. 25.8%, p = 0.033). Patients with advanced-stage endometrial cancer who underwent open surgery had a significantly lower disease-free survival (p = 0.029) than those who underwent minimally invasive surgery, however, the overall survival (p = 0.051) was similar between the two groups. Conclusion: Minimally invasive surgery showed better survival outcomes when compared to open surgery in advanced-stage EC patients irrespective of the histologic type.

Preoperative neutrophil-to-lymphocyte, platelet-to-lymphocyte and monocyte-to-lymphocyte ratio as a prognostic factor in non-endometrioid endometrial cancer

Objective: Evaluate the prognostic value of neutrophil-lymphocyte ratio (NMR), platelet-lymphocyte ratio (PLR), and monocyte-lymphocyte ratio (MLR) in patients with non-endometrioid endometrial cancer. Method: Laboratory and clinicopathological data from 118 patients with non-endometrioid endometrial cancer who underwent surgical resection between January 2010 and December 2019 were reviewed. NLR, PLR and MLR were analyzed for correlations with recurrence and survival. The receiver operating characteristic (ROC) curves were generated for the NLR, PLR, and MLR. Optimal cut-off values were determined as the points at which the Youden index (sensitivity + specificity - 1) was maximal. Based on the results of the ROC curve analysis, the patients were grouped into high MLR and low MLR groups. Recurrence rate, disease-free survival, and overall survival were compared between the two groups. The prognostic factors were investigated using univariate and multivariate Cox proportional hazards model. Results: The optimal cut-off value of MLR was 0.191 (AUC, 0.718; p < 0.001). Significantly more patients in the high MLR group experienced recurrence (60.3% vs. 15.6%, p < 0.0001) and cancer-related deaths (46.6% vs. 13.3%, p = 0.003). In multivariate analysis, advanced stage and high MLR were independent prognostic factors for disease-free survival and overall survival. Conclusion: Elevated MLR was significantly associated poor clinical outcomes in patients with non endometrioid endometrial cancer. Our findings suggest that MLR may be clinically reliable and useful as an independent prognostic marker for patients with non-endometrioid endometrial cancer.

Prediction of lymphovascular space invasion in patients with endometrial cancer

Objective: Predict the presence of lymphovascular space invasion (LVSI), using uterine factors such as tumor diameter (TD), grade, and depth of myometrial invasion (MMI). Develop a predictive model that could serve as a marker of LVSI in women with endometrial cancer (EC). Methods: Data from 888 patients with endometrioid EC who were treated between January 2009 and December 2018 were reviewed. The patients' data were retrieved from six institutions. We assessed the differences in the clinicopathological characteristics between patients with and without LVSI. We performed logistic regression analysis to determine which clinicopathological characteristics were the risk factors for positive LVSI status and to estimate the odds ratio (OR) for each covariate. Using the risk factors and OR identified through this process, we created a model that could predict LVSI and analyzed it further using receiver operating characteristic curve analysis. Results: In multivariate logistic regression analysis, tumor size (P = 0.027), percentage of MMI (P < 0.001), and presence of cervical stromal invasion (P = 0.002) were identified as the risk factors for LVSI. Based on the results of multivariate logistic regression analysis, we developed a simplified LVSI prediction model for clinical use. We defined the "LVSI index" as "TD×%MMI×tumor grade×cervical stromal involvement." The area under curve was 0.839 (95% CI= 0.809-0.869; sensitivity, 74.1%; specificity, 80.5%; negative predictive value, 47.3%; positive predictive value, 8.6%; P < 0.001), and the optimal cut-off value was 200. Conclusion: Using the modified risk index of LVSI, it is possible to predict the presence of LVSI in women with endometrioid endometrial cancer. Our prediction model may be an appropriate tool for integration into the clinical decision-making process when assessed either preoperatively or intraoperatively.

Survival rates of patients who undergo minimally invasive surgery for endometrial cancer with cervical involvement

Objective: Compare the oncologic outcomes of patients with intermediate-risk endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery. Methods: Data from 206 patients with intermediate-risk endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 206 patients included in this study, 76 underwent open surgery (36.9%) and 130 underwent MIS (63.1%). In patients with stage IB endometrial cancer, the recurrence rate, disease-free survival, and overall survival were not significantly different between those who underwent minimally invasive surgery and those who underwent open surgery. However, in patients with stage II endometrial cancer, the recurrence rate was significantly higher among those who underwent minimally invasive surgery (37.5% vs. 5.3%, p = 0.013). Patients with stage II endometrial cancer who underwent minimally invasive surgery had a significantly lower disease-free survival (p = 0.012) than those who underwent open surgery, however, the overall survival (p = 0.252) was similar between the two groups. Conclusion: Minimally invasive surgery results in less favorable survival outcomes than open surgery in patients with stage II endometrial cancer.

Comparison of abdominal and minimally invasive radical hysterectomy in patients with early stage cervical cancer

PURPOSE

The aim of this study was to compare survival outcomes of open radical hysterectomy and minimally invasive radical hysterectomy (MIS) in early stage cervical cancer.

METHODS

A retrospective analysis of 148 patients with stage IB1 - IIA2 cervical cancer who underwent either minimally invasive or open radical hysterectomy. Tumor characteristics, recurrence rate, disease-free survival (DFS), and overall survival (OS) were compared according to surgical approach.

RESULTS

In total, 110 and 38 patients were assigned to open surgery and MIS groups. After a medical follow-up of 42.1 months, the groups showed similar survival outcomes (recurrence rate, DFS, and OS). However, in patients with tumor size >2 cm, recurrence rate was significantly higher in MIS group (22.5% vs 0%; p=0.008). And in patients with tumor size >2 cm, MIS group showed significantly poorer DFS than open surgery group (p=0.017), although OS was similar between the two groups (p=0.252).

CONCLUSION

In patients with tumor size >2 cm, MIS was associated with higher recurrence rates and poorer DFS than open surgery. However, in patients with tumor size ≤2 cm, MIS did not seem to compromise oncologic outcomes.

Associations of depression and anxiety with cardiovascular risk among people living with HIV/AIDS in Korea

OBJECTIVES

As HIV/AIDS is becoming a chronic disease, the risk of developing cardiovascular disease (CVD) among people living with HIV/AIDS is rising. Anxiety and depression, which are common among people living with HIV/AIDS, have been linked with CVD. This study investigated the risk of CVD in people living with HIV/AIDS and explored the effects of depression and anxiety on CVD risk.

METHODS

Data were collected for 457 people enrolled in the Korea Cohort HIV/AIDS study after 2010. Framingham risk scores were calculated to quantify the 10-year risk of developing CVD. Depression and anxiety variables were re-coded as a single combined variable. Multivariable logistic regression analysis was performed, adjusting for age, body mass index, low-density lipoprotein (LDL) cholesterol, triglycerides (TG), duration of human immunodeficiency virus (HIV) positivity after entry into the cohort, and depression/anxiety.

RESULTS

Participants with both depression and anxiety were 2.28 times more likely than those with neither depression nor anxiety to have moderate/high-risk CVD risk. The 10-year risk of developing CVD was affected by LDL cholesterol, TG, age, and duration of HIV infection. LDL cholesterol and TG levels change according to the duration of HIV infection, and metabolic disorders affect the risk of CVD. Thus, a longer duration of HIV infection is associated with a higher risk of developing CVD.

CONCLUSIONS

Screenings for depression and anxiety need to be provided regularly to assess the severity of those symptoms. To help decrease their risk of developing CVD, people living with HIV/AIDS should be offered behavioral modification interventions aimed at developing healthy lifestyle habits.

A Systematic Narrative Review of Comprehensive Preparedness Strategies of Healthcare Resources for a Large Resurgence of COVID-19 Nationally, with Local or Regional Epidemics: Present Era and Beyond

Coronavirus disease 2019 (COVID-19) has penetrated our daily lives, leading us to a new normal era. The unexpected impact of COVID-19 has posed a unique challenge for the health care system, bringing innovation around the world. Considering the current pandemic pattern, comprehensive preparedness strategies of healthcare resources need to be implemented to prepare for a large resurgence of COVID-19 within a short time. With the unprecedented spread of the new pandemic and the impending influenza season, scientific evidence-based schemes need to be developed through cooperation, coordination, and solidarity. Based on the early experience with the current pandemic, this narrative interpretive review of qualitative studies suggests a 6-domain plan to establish a better health care system that is prepared to deal with the current and future public health crises. The 6 domains are medical institutions, medical workforce, medical equipment, COVID-19 surveillance, data and information application, and governance structure.

Incidence and Risk Factors of Gastrointestinal and Hepatobiliary Complications after Spinal Fusion Surgery: a Retrospective Cohort Study

BACKGROUND

Spinal surgery holds a higher chance of unpredicted postoperative medical complications among orthopedic surgeries. Several studies have analyzed the risk factors for diverse postoperative medical complications, but the majority investigated incidences of each complication qualitatively. Among gastrointestinal complications, reports regarding postoperative ileus were relatively frequent. However, risk factors or incidences of hepatobiliary complications have yet to be investigated. The purpose of this study was to examine the incidence of gastrointestinal complications after spinal surgery, quantitatively analyze the risk factors of frequent complications, and to determine cues requiring early approaches.

METHODS

In total, 234 consecutive patients who underwent spinal fusion surgery performed by one senior doctor at our institute in one-year period were retrospectively enrolled for analyses. The primary outcomes were presence of paralytic ileus, elevated serum alanine transaminase (ALT) and aspartate transaminase (AST) levels, and elevated total bilirubin levels. Univariate logistic regression analyses of all variables were performed. In turn, significant results were reanalyzed by multivariate logistic regression. The variables used were adjusted with age and gender.

RESULTS

Gastrointestinal complications were observed in 15.8% of patients. Upon the risk factors of postoperative ileus, duration of anesthesia (odds ratio [OR], 1.373; P = 0.015), number of fused segments (OR, 1.202; P = 0.047), and hepatobiliary diseases (OR, 2.976; P = 0.029) were significantly different. For elevated liver enzymes, men (OR, 2.717; P = 0.003), number of fused segments (OR, 1.234; P = 0.033), and underlying hepatobiliary (OR, 2.704; P = 0.031) and rheumatoid diseases (OR, 5.021; P = 0.012) had significantly different results. Lastly, risk factors for total bilirubin elevation were: duration of anesthesia (OR, 1.431; P = 0.008), number of fused segments (OR, 1.359; P = 0.001), underlying hepatobiliary diseases (OR, 3.426; P = 0.014), and thoracolumbar junction involving fusions (OR, 4.134; P = 0.002) compared to lumbar spine limited fusions.

CONCLUSION

Patients on postoperative care after spinal surgery should receive direct attention as soon as possible after manifesting abdominal symptoms. Laboratory and radiologic results must be carefully reviewed, and early consultation to gastroenterologists or general surgeons is recommended to avoid preventable complications.

Antiviral activity of digoxin and ouabain against SARS-CoV-2 infection and its implication for COVID-19

The current coronavirus (COVID-19) pandemic is exacerbated by the absence of effective therapeutic agents. Notably, patients with COVID-19 and comorbidities such as hypertension and cardiac diseases have a higher mortality rate. An efficient strategy in response to this issue is repurposing drugs with antiviral activity for therapeutic effect. Digoxin (DIG) and ouabain (OUA) are FDA drugs for heart diseases that have antiviral activity against several coronaviruses. Thus, we aimed to assess antiviral activity of DIG and OUA against SARS-CoV-2 infection. The half-maximal inhibitory concentrations (IC50) of DIG and OUA were determined at a nanomolar concentration. Progeny virus titers of single-dose treatment of DIG, OUA and remdesivir were approximately 103-, 104- and 103-fold lower (> 99% inhibition), respectively, than that of non-treated control or chloroquine at 48 h post-infection (hpi). Furthermore, therapeutic treatment with DIG and OUA inhibited over 99% of SARS-CoV-2 replication, leading to viral inhibition at the post entry stage of the viral life cycle. Collectively, these results suggest that DIG and OUA may be an alternative treatment for COVID-19, with potential additional therapeutic effects for patients with cardiovascular disease.

Prospective cohort data quality assurance and quality control strategy and method: Korea HIV/AIDS Cohort Study

OBJECTIVES

The aim of effective data quality control and management is to minimize the impact of errors on study results by identifying and correcting them. This study presents the results of a data quality control system for the Korea HIV/AIDS Cohort Study that took into account the characteristics of the data.

METHODS

The HIV/AIDS Cohort Study in Korea conducts repeated measurements every 6 months using an electronic survey administered to voluntarily consenting participants and collects data from 21 hospitals. In total, 5,795 sets of data from 1,442 participants were collected from the first investigation in 2006 to 2016. The data refining results of 2015 and 2019 were converted into the data refining rate and compared.

RESULTS

The quality control system involved 3 steps at different points in the process, and each step contributed to data quality management and results. By improving data quality control in the pre-phase and the data collection phase, the estimated error value in 2019 was 1,803, reflecting a 53.9% reduction from 2015. Due to improvements in the stage after data collection, the data refining rate was 92.7% in 2019, a 24.21%p increase from 2015.

CONCLUSIONS

Despite this quality management strategy, errors may still exist at each stage. Logically possible errors for the post-review refining of downloaded data should be actively identified with appropriate consideration of the purpose and epidemiological characteristics of the study data. To improve data quality and reliability, data management strategies should be systematically implemented.

Survival Trend of HIV/AIDS Patients Starting Antiretroviral Therapy in South Korea between 2001 and 2015

PURPOSE

In the recent antiretroviral therapy (ART) era, a large proportion of Korean patients with human immunodeficiency virus (HIV) infection were shown to have low CD4 cell counts at diagnosis and during ART initiation. We investigated the survival trends in patients living with HIV/acquired immunodeficiency syndrome (AIDS) in Korea who started ART in the 2000s, and evaluated the risk factors for mortality to elucidate the association between survival and low CD4 cell counts at ART initiation.

MATERIALS AND METHODS

Patients with HIV infection who were aged >18 years and had started ART between 2001 and 2015 in the Korean HIV/AIDS cohort study were enrolled. We compared the clinical characteristics, mortality, and causes of death among the enrolled subjects based on the time of ART initiation. Cox regression analysis was used to estimate the adjusted hazard ratios of mortality based on the time of ART initiation.

RESULTS

Among the 2474 patients enrolled, 105 (4.24%) died during the follow-up period of 9568 patient-years. Although CD4 cell counts at the time of ART initiation significantly increased from 161 [interquartile range (IQR), 73.5-303] in 2001-2003 to 273 (IQR, 108-399) in 2013-2015 (p<0.001), they remained low during the study period. The incidence of all-cause mortality was 10.97 per 1000 patient-years during the study period. There was no decreasing trend in mortality between 2001 and 2015. Age >40 years [adjusted hazard ratio, 3.71; 95% confidence interval (CI), 2.35-5.84] and low CD4 counts (<100 cells/mm³: adjusted hazard ratio, 2.99; 95% CI, 1.44-6.23) were significant risk factors for mortality.

CONCLUSION

Despite excellent HIV care available in the recent ART era, the survival of patients with HIV/AIDS undergoing ART did not improve between 2001 and 2015 in Korea.

Walk-Through Screening Center for COVID-19: an Accessible and Efficient Screening System in a Pandemic Situation

With the ongoing novel coronavirus disease 2019 (COVID-19) pandemic, the number of individuals that need to be tested for COVID-19 has been rapidly increasing. A walk-through (WT) screening center using negative pressure booths that is inspired by the biosafety cabinet has been designed and implemented in Korea for easy screening of COVID-19 and for safe and efficient consultation for patients with fever or respiratory symptoms. Here, we present the overall concept, advantages, and limitations of the COVID-19 WT screening center. The WT center increases patient access to the screening clinics and adequately protects healthcare personnel while reducing the consumption of personal protective equipment. It can also increase the number of people tested by 9-10 fold. However, there is a risk of cross-infection at each stage of screening treatment, including the booths, and adverse reactions with disinfection of the booths. These limitations can be overcome using mobile technology and increasing the number of booths to reduce congestion inside the center, reducing booth volume for sufficient and rapid ventilation, and using an effective, harmless, and certified environmental disinfectant. A WT center can be implemented in other institutions and countries and modified depending on local needs to cope with the COVID-19 pandemic.

Trabecular bone scores in young HIV-infected men: a matched case-control study

Background

Screening for osteoporosis with dual-energy X-ray absorptiometry (DXA) is recommended for male HIV-infected patients only above the age of 50. Recently, trabecular bone score (TBS) has been introduced as a novel tool to assess bone microarchitecture using DXA of the lumbar spine. Few studies have reported TBS values in HIV-infected individuals younger than 50 years of age. This study compared TBS values in young males infected with HIV and matched controls, and investigated the associations between TBS and demographic parameters, clinical parameters, and bone mineral density (BMD) scores.

Methods

A cross-sectional study of BMD and TBS in HIV-infected men (n = 80) aged between 18 and 50 years and age- and sex-matched controls (n = 80) was conducted.

Results

The proportion of patients with low BMD (Z-score ≤ − 2) was significantly greater among HIV-infected patients than among matched controls (21.3% [17/80] vs. 8.8% [7/80], p = 0.027). Mean TBS values were significantly lower in HIV-infected patients than in controls (1.41 ± 0.07 vs. 1.45 ± 0.07, p = 0.008). In both groups, TBS values were positively correlated with BMD at the lumbar spine, femoral neck, and total hip (p < 0.001); however, TBS was not correlated with body mass index. In the HIV group, TBS was negatively correlated with the duration of tenofovir disoproxil fumarate(TDF) exposure (p = 0.04).

Conclusion

Young men infected with HIV had abnormal bone trabecular microarchitecture, as assessed by both TBS and BMD. TBS values were correlated with both BMD and the duration of TDF exposure.

Significance of Increased Rapid Treatment from HIV Diagnosis to the First Antiretroviral Therapy in the Recent 20 Years and Its Implications: the Korea HIV/AIDS Cohort Study

From December 2006 to December 2016, 1,429 patients enrolled in the Korea human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) Cohort Study were investigated. Based on the year of diagnosis, the time interval between HIV diagnosis and initiation of antiretroviral therapy (ART) was analyzed by dividing it into 2 years. The more recent the diagnosis, the more likely rapid treatment was initiated (P < 0.001) and the proportion of patients starting ART on the same day of HIV diagnosis was increased in 2016 (6.5%) compared to that in 2006 (1.7%). No significant difference in the median values of CD4+ cell counts according to the diagnosis year was observed. In the past 20 years, the time from the HIV diagnosis to the initiation of ART was significantly reduced. Rapid treatment was being implemented at the HIV diagnosis, regardless of CD4+ cell count. Considering the perspective "treatment is prevention," access to more rapid treatment is necessary at the time of HIV diagnosis.

Epidemiological characteristics of HIV infected Korean: Korea HIV/AIDS Cohort Study

OBJECTIVES

To manage evidence-based diseases, it is important to identify the characteristics of patients in each country.

METHODS

The Korea HIV/AIDS Cohort Study seeks to identify the epidemiological characteristics of 1,442 Korean individuals with human immunodeficiency virus (HIV) infection (12% of Korean individuals with HIV infection in 2017) who visited 21 university hospitals nationwide. The descriptive statistics were presented using the Korea HIV/AIDS cohort data (2006-2016).

RESULTS

Men accounted for 93.3% of the total number of respondents, and approximately 55.8% of respondents reported having an acute infection symptom. According to the transmission route, infection caused by sexual contact accounted for 94.4%, of which 60.4% were caused by sexual contact with the same sex or both males and females. Participants repeatedly answered the survey to decrease depression and anxiety scores. Of the total participants, 89.1% received antiretroviral therapy (ART). In the initial ART, 95.3% of patients were treated based on the recommendation. The median CD4 T-cell count at the time of diagnosis was 229.5 and improved to 331 after the initial ART. Of the patients, 16.6% and 9.4% had tuberculosis and syphilis, respectively, and 26.7% had pneumocystis pneumonia. In the medical history, sexually transmitted infectious diseases showed the highest prevalence, followed by endocrine diseases. The main reasons for termination were loss to follow-up (29.9%) and withdrawal of consent (18.7%).

CONCLUSIONS

Early diagnosis and ART should be performed at an appropriate time to prevent the development of new infection.

Invasive fungal infection in liver transplant recipients in a prophylactic era: A multicenter retrospective cohort study in Korea

The epidemiology of invasive fungal infections (IFIs) after liver transplantation (LT) is continuing to evolve in the current era of antifungal prophylactic therapy. This multicenter retrospective cohort study aimed to evaluate the epidemiology, risk factors, and outcomes of IFIs among LT recipients in the current era.We analyzed a total of 482 LT recipients aged 18 years and older who were admitted to 3 tertiary hospitals in Korea between January 2009 and February 2012.Twenty-four episodes of IFIs occurred in 23 patients (4.77%; 23/482). Of these episodes, 20 were proven cases and 4 were probable cases according to EORTC/MSG criteria. Among these cases, IFI developed within 30 days of transplantation in 47.8% of recipients, from 31 to 180 days in 34.8% of recipients, and from 181 to 365 days in 17.4% of recipients. The most common isolates were Candida species (n = 12, 52.2%; Candida albicans, 6 cases; Candida tropicalis, 1 case; Candida glabrata, 1 case; Candida parapsilosis, 1 case; and unspecified Candida species, 1 case) and Aspergillus species (n = 7, 30.4%). The mortality in patients with IFIs was significantly higher than that in patients without IFIs (47.83% [11/23] vs 7.18% [33/459], P < .001). The incidence of late-onset IFIs is increasing in the antifungal prophylactic era, and fluconazole-resistant non-albicans Candida species have not yet emerged in Korea.

Prognosis of liver abscess with no identified organism

BACKGROUND

There are limited studies focusing on liver abscess with negative microbiological cultures. This study evaluated the clinical and prognostic differences of patients with culture-negative liver abscess (CNLA) compared to those with a positive culture (CPLA) and compared these factors between K. pneumoniae liver abscess (KLA) and E. coli liver abscess (ELA).

METHODS

A retrospective study of the patients who admitted with a liver abscess at two tertiary hospitals in Korea from 2012 to 2016 was performed.

RESULTS

Among a total of 402 patients with liver abscess, 61.2% had positive cultures. K. pneumoniae (n = 133) was the most common cause, followed by E. coli (n = 74). Patients with CPLA were significantly older (p = 0.02) and more frequently had cholelithiasis or biliary tract disease (p = 0.001) compared to patients with CNLA. In-hospital mortality (p = 0.63) and recurrence (p = 0.77) were no different between the two groups. The length of hospital stay was significantly longer in patients with CPLA (p = 0.03) compared with those with CNLA. Subgroup analysis for patients who received 3rd generation cephalosporins empirically showed that in-hospital mortality (p = 0.18) and recurrence (p = 0.27) were not also significantly different. Cholelithiasis, or biliary tract disease (p = 0.001), liver disease (p = 0.001), malignancy (p = 0.0001), and ESBL production (p = 0.0001) were found more frequently in patients with ELA compared with those with KLA.

CONCLUSIONS

The prognosis of the CNLA patients was similar to that of the CPLA patients, although the length of hospital stay was shorter in the CNLA patients. The epidemiologic and clinical characteristics of the ELA patients are somewhat different than those of the KLA patients.

Long-Term Outcomes of Renal Function After Adult Intestinal Transplantation at a Single Small-Volume Center: 2 Cases of Renal Transplantation

PURPOSE

Renal dysfunction more frequently occurs after intestinal transplantation (ITx) than after heart, lung, or liver transplantation. We provide a clinical analysis of renal function after adult ITx.

METHODS

We retrospectively analyzed 8 adult ITx patients who survived for at least 6 months between 2004 and 2018. Glomerular filtration rate (GFR) measurements were performed at baseline, at 3 and 6 months post-transplantation, and yearly. The median follow-up duration was 53.5 months.

RESULTS

All cases were isolated ITx; 3 received living-donor ITx, and 5 received deceased-donor ITx. The mean baseline GFR was 97 mL/min/1.73 m². The GFR had decreased by more than 50% of baseline at 1 year post-transplant. Renal dysfunction was observed in 4 patients. Two patients developed acute kidney injury due to acute rejection and sepsis. One of these patients fully recovered renal function, but the second patient died. Another 2 patients developed chronic kidney disease and required hemodialysis (HD) within 6 and 3 years, respectively. The first living-donor ITx patient lost renal function progressively over 6 years after ITx. She received a renal graft from the same living donor as for the ITx after 3 years of HD. The other patient (deceased-donor ITx) received a kidney from his daughter at 5 months after HD.

CONCLUSIONS

To obtain an accurate assessment of renal function, frequent direct measurements of GFR should be performed to facilitate early diagnosis of renal impairment and to determine subsequent strategies to improve renal function after ITx.

Differences in autophagy-associated mRNAs in peritoneal fluid of patients with endometriosis and gynecologic cancers

Endometriosis and gynecologic cancer show similar patterns of invasion. Little is known about the roles of autophagy in endometriosis and, to date, the expression of autophagy-associated mRNAs has not been compared in patients with endometriosis and gynecologic cancers. This study therefore compared the levels of expression of autophagy-associated mRNAs in patients with endometriosis and gynecologic cancers. The levels of autophagy mRNAs, including those encoding mTOR, P13KC3, Beclin-1, Bcl-2, LC3 II, FLIP, Rubicon, BIRC2 and BIRC5, were measured by real time polymerase chain reaction in peritoneal fluid of 27 patients with benign masses (control group), 42 patients with endometriosis, and 43 patients with gynecologic (ovarian, uterine, and cervical) cancers. Findings in the three groups were compared. Autophagy mRNAs were present in all samples from patients with endometriosis and gynecologic cancers. The levels of PI3K, FLIP, and Rubicon mRNAs were significantly higher in the endometriosis than in the control group (p < 0.05 each). Compared with the gynecologic cancer group, the levels of LC3II and FLIP mRNAs were significantly lower, and the levels of Beclin-1 and Rubicon mRNAs significantly higher, in the endometriosis group (p < 0.05 each). Levels of PI3K and FLIP mRNA were significantly higher in the endometriosis and gynecologic cancer groups than in the control group (p < 0.05 each). PI3K, FLIP, and Rubicon mRNAs are closely associated with the pathogenesis of endometriosis. The similar increases in PI3K and FLIP mRNA expression observed in patients with endometriosis and gynecologic cancer suggest that these conditions have similar autophagic characteristics. The lower levels of Beclin-1 mRNA in the gynecologic cancer than in other two groups suggest that lower Beclin-1 mRNA levels increase the likelihood of developing gynecologic cancer.