Search for the Pair Production of Dark Particles X with K_{L}

We present the first search for the pair production of dark particles X via K_{L}^{0}→XX with X decaying into two photons using the data collected by the KOTO experiment. No signal was observed in the mass range of 40-110 MeV/c^{2} and 210-240 MeV/c^{2}. This sets upper limits on the branching fractions as B(K_{L}^{0}→XX)<(1-4)×10^{-7} and B(K_{L}^{0}→XX)<(1-2)×10^{-6} at the 90% confidence level for the two mass regions, respectively.

Application of inorganic phosphate limitation to efficient isoprene production in Pantoea ananatis.

AIMS: Establishment of an efficient isoprene fermentation process by adopting inorganic phosphate limitation as the trigger to direct metabolic flux to the isoprene synthetic pathway. METHODS AND RESULTS: We constructed isoprene-producing strains of Pantoea ananatis (a member of the Enterobacteriaceae family) by integrating a heterologous mevalonate pathway and a metabolic switch that senses external inorganic phosphate (Pi) levels. This metabolic switch enabled dual-phase isoprene production, where the initial cell growth phase under Pi-saturating conditions was uncoupled from the subsequent isoprene production phase under Pi-limiting conditions. In fed-batch fermentation using our best strain (SWITCH-PphoC/pIspSM) in a 1-l bioreactor, isoprene concentration in the off-gas was maintained between 300 and 460 ppm during the production phase and at 20 ppm during the cell growth phase, respectively. The strain SWITCH-PphoC/pIspSM produced totally 2·5 g l-1 of isoprene from glucose with a 1·8% volumetric yield in 48 h. CONCLUSIONS: This proof-of-concept study demonstrated that our Pi-dependent dual-phase production system using a P. ananatis strain as a producer has potential for industrial-scale isoprene fermentation. SIGNIFICANCE AND IMPACT OF THE STUDY: This Pi-dependent dual-phase fermentation process could be an attractive and economically viable option for the production of various commercially valuable isoprenoids.

Large-Scale Channel Migration in the Sittang River Estuary.

An estuary is a dynamic environment where marine and fluvial processes meet to form complex and transient morphology. The estuary morphology is largely determined by net sediment transport by two-way tidal flows, but the hydrodynamics also depends on the morphology of the tidal channels. The estuary inherently accommodates cyclic processes that are internally generated through hydro-morphodynamic interactions. In addition, the estuary evolves in response to changes in external forces by natural and anthropogenic factors. Morphological changes under the different controls often hinder the comprehension of the evolutionary processes of estuaries. Here we explored morphological changes in the Sittang River estuary, Myanmar, which has great morphological dynamism from extreme tidal energy and large sediment inputs, through field surveys and satellite imagery analysis. We identify an autocyclic process in a sedimentary system driving large-scale channel migration in decadal to multidecadal cycles. We show that drastic changes of the estuary morphology occasionally occur with rapid bank erosion through modulation of the cyclic channel migration under conflicting tidal and fluvial forces. This extreme case with minimal human intervention highlights channel migration as a key process in morphological evolution of tide-dominated estuaries undergoing active infilling.

Prognostic significance of preoperative inflammatory response biomarkers in patients undergoing curative thoracoscopic esophagectomy for esophageal squamous cell carcinoma.

BACKGROUND: Recent studies have revealed significant relationships between the lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) and survival in various cancers. The purpose of this study was to confirm whether the LMR, NLR, and PLR have prognostic values, independent of clinicopathological criteria, in patients undergoing curative resection for esophageal cancer. METHODS: The LMR, NLR and PLR were calculated in 147 consecutive patients who underwent curative esophagectomy between January 2006 and December 2014. Receiver operating characteristics (ROC) curve analysis was conducted to identify the optimal cutoff values of each biomarkers. RESULTS: In multivariate analysis for cancer-specific survival (CSS), pTNM stage (p < 0.0001) and low LMR (p = 0.0081) were selected as independent prognostic factor. Similarly, pTNM stage(p < 0.0001) and low LMR (p = 0.0225) were found to be independent prognostic factor for overall survival (OS). There was no significant relationship between LMR, NLR and PLR and survival in patients with stage I or II, however, significant relationships between LMR and CSS or OS were observed in patients with stage III esophageal cancer. CONCLUSIONS: LMR can be used as a novel predictor of postoperative CSS and OS in patients with esophageal cancer and that it may be useful in identifying patients with a poor prognosis even after radical esophagectomy.

Modified total meso-pancreatoduodenum excision with pancreaticoduodenectomy as a mesopancreatic plane surgery in borderline resectable pancreatic cancer.

BACKGROUND: A superior mesenteric artery (SMA)-first approach has been considered to be an efficient technique in pancreaticoduodenectomy when the SMA is a factor of borderline resectable pancreatic head cancer (BRPHC). However, this excellent procedure has limitations in terms of tumor resection with an intact coverage including the pancreatic tumor and the tumor-draining lymphovascular systems and the ability to achieve a complete regional lymphadenectomy. METHODS: A modified mesenteric plane procedure has been developed that provides improved regional lymphadenectomy and permits adjustment of the surgical approach, which is based on the direction of the tumor infiltration. RESULTS: Of 55 patients taken to surgery, 19 had peritoneal dissemination and/or liver metastasis at staging laparoscopy, and the procedure revealed tumor infiltration to the SMA and/or hepatic artery (HA) in 4 patients. Finally, 32 patients with BRPHC have undergone the procedure between April 2009 and June 2015. Twenty-four of 32 patients (75.0%) had negative resection margins, and the median number of lymph nodes harvested was 34. Lymph nodes around the SMA tested positive for metastasis in 13 patients (40.6%), and those around the HA tested positive for metastasis in 7 patients (21.9%). Complications occurred in 14 patients (43.7%), with no perioperative mortality. Overall survival rates were 65.3% at 1 year and 35.2% at 3 years. CONCLUSIONS: Short-term results with the procedure may encourage surgical management for BRPHC.

Feasibility of intensity-modulated radiotherapy combined with gemcitabine and S-1 for patients with pancreatic cancer.

The aim of the present study was to establish whether intensity-modulated radiotherapy (IMRT) with concurrent gemcitabine and S-1 is a feasible treatment option for patients with locally advanced pancreatic ductal adenocarcinoma. Patients with pancreatic ductal adenocarcinoma were prospectively enrolled. An IMRT dose of 50.4 Gy in 28 fractions with concurrent gemcitabine at a dose of 600 mg/m2 and S-1 at a dose of 60 mg were administrated. Adverse events and associated dosimetric factors were assessed. Between February 2012 and January 2014, 17 patients with borderline resectable and 4 with unresectable pancreatic cancer were enrolled. None of the patients experienced grade 3 or worse nausea and vomiting. The planning target volume (≥200 vs. <200 ml) was a statistically significant predictive factor for neutrocytopenia (≥500 vs. 500/µl, P=0.02). Concurrent IMRT with gemcitabine and S-1 for patients with locally advanced pancreatic cancer is feasible, with tolerable hematological toxicities and low gastrointestinal toxicities.

Impact of inflammation-based prognostic score on survival after curative thoracoscopic esophagectomy for esophageal cancer.

BACKGROUND: Despite recent improvements in early detection, progress in surgical techniques, and development of chemoradiation therapies, prognosis of esophageal cancer remains poor. The aim of the present study was to assess whether Glasgow Prognostic Score (GPS), an inflammation-based prognostic score, has prognostic value independent of conventional clinicopathological criteria in patients undergoing curative resection for esophageal cancer, even in elderly patients. METHODS: We retrospectively reviewed the database of 141 consecutive patients with histologically verified esophageal squamous cell carcinoma who underwent potentially curative surgery in our institute, between January 2006 and December 2014. GPS and neutrophil lymphocyte ratio (NLR) were calculated. RESULTS: On multivariate analysis, TNM stage (p < 0.0001) and GPS (p = 0.041) were independently associated with worse prognosis in overall patients with esophageal cancer. Multivariate analysis evaluated the prognostic factors in two different patient groups: patients younger than 70 years (non-elderly) and those aged 70 years or more (elderly). Multivariate analysis demonstrated that TNM stage (p = 0.0003) was an only independent risk factor for a worse prognosis among non-elderly group. Meanwhile, multivariate analysis demonstrated that TNM stage (p = 0.001) and GPS (p = 0.043) were the independent risk factor for a worse prognosis among elderly group. CONCLUSION: The present study demonstrated that GPS is associated with prognosis and can be considered as an independent prognostic marker in patients who underwent esophagectomy. Moreover, the GPS has the advantage of being simple to measure, routinely available and well standardized. But the present study failed to confirm the NLR as a significant predictor of survival following resection for esophageal cancer.

Impact of the duration of hormonal therapy following radiotherapy for localized prostate cancer.

External-beam radiotherapy (EBRT) combined with androgen deprivation therapy (ADT) is known to provide improved survival outcomes compared with EBRT alone in the treatment of prostate cancer; however, the use of ADT has been reported to be associated with adverse events. Accordingly, the aim of the present study was to clarify the adequate duration of ADT when combined with EBRT to treat patients with high-risk localized prostate cancer, with consideration of survival outcomes and toxicity. Between 2001 and 2011, 173 patients with high-risk localized prostate cancer received ADT combined with EBRT, at a median dose of 69.6 Gy. Of these, 54 (31%) underwent short-term ADT (<36 months) and 119 (69%) underwent long-term ADT (≥36 months). During the median follow-up period of 54 months, the five-year progression-free survival rate of patients receiving short-term ADT (72.9%) was significantly lower than that of patients receiving long-term ADT (92.8%) (P<0.01). Furthermore, the incidence of cardiovascular toxicity at grade II or above was significantly higher amongst patients treated with short-term ADT compared with patients treated with long-term ADT (P<0.01). Thus, the present study determined that ADT for ≥36 months combined with EBRT significantly improved the progression-free survival of patients with high-risk localized prostate cancer and exhibited an acceptable toxicity profile.

Dosimetric evaluation of compensator intensity modulation-based stereotactic body radiotherapy for Stage I non-small-cell lung cancer.

OBJECTIVE: To evaluate the dosimetry of compensator intensity modulation-based stereotactic body radiotherapy (SBRT) [non-coplanar intensity-modulated radiotherapy (ncIMRT)], its use was compared with that of three-dimensional conformation-based SBRT, for patients with Stage I non-small-cell lung cancer (NSCLC). METHODS: 21 consecutive patients with Stage I NSCLC were treated with ncIMRT or SBRT at Tokyo Medical University. To compare the two techniques, ncIMRT and SBRT plans for each patient were generated, where the planning target volume (PTV) coverages were adjusted to be equivalent to each other. The prescribed dose was set as 75 Gy in 30 fractions. PTV coverage, conformity index, conformation number (CN) and homogeneity index (HI) were used to compare the two strategies. RESULTS: There was no statistically significant difference between PTV coverage for the 100%, 95% and 90% dose levels in the SBRT plan and those in the ncIMRT plan. The CN values were 0.53 ± 0.13 in the SBRT plan and 0.72 ± 0.10 in the ncIMRT plan. These values were significantly better than those of the SBRT plan (p < 0.001). The HI in the ncIMRT plan was 1.04 ± 0.03%, which was also significantly better than that of SBRT. CONCLUSION: The ncIMRT plan provided superior conformity and reduced the doses to the lung for patients with Stage I NSCLC. ADVANCES IN KNOWLEDGE: The delivery technique with compensator intensity modulation-based SBRT was evaluated. Concerning target motion, this is thought to be more robust and safer than SBRT for early-stage NSCLC.

Patients with severe emphysema have a low risk of radiation pneumonitis following stereotactic body radiotherapy.

OBJECTIVE: To evaluate the risk of radiation pneumonitis (RP) after stereotactic radiotherapy (SBRT) for patients presenting with severe pulmonary emphysema. METHODS: This study included 40 patients with Stage I non-small-cell lung cancer who underwent SBRT, 75 Gy given in 30 fractions, at the Tokyo Medical University, Tokyo, Japan, between February 2010 and February 2013. The median age of the patients was 79 years (range, 49-90 years), and the male:female ratio was 24:16. There were 20 T1 and 20 T2 tumours. 17 patients had emphysema, 6 had slight interstitial changes on CT images and the remaining 17 had no underlying lung disease. The level of emphysema was classified into three groups according to the modified Goddard's criteria (severe: three patients, moderate: eight patients and mild: six patients). Changes in the irradiated lung following SBRT were evaluated by CT. RESULTS: On CT images, RP was detected in 34 (85%) patients, and not in 6 (15%) patients, during a median observation period of 313 days. Of the six patients, three had severe emphysema and three had no underlying lung disease. Patients with severe emphysema had lower risk of RP than those with moderate emphysema (p = 0.01), mild emphysema (p = 0.04) and no underlying lung disease (p = 0.01). CONCLUSION: Patients with severe emphysema had a low risk of RP following SBRT. ADVANCES IN KNOWLEDGE: Little is known about the association between RP and pulmonary emphysema. Patients with severe emphysema had lower risk of RP than those with no underlying lung disease.

Safety and Feasibility of a Pancreaticoduodenectomy with Total Meso-Pancreatoduodenum Excision: Analysis in Various Periampullary Disorders.

BACKGROUND/AIMS: This study aimed to evaluate the safety and feasibility of a pancreaticoduodenectomy with total meso-pancreatoduodenum excision (tMPDe) as an new anatomical concept. METHODOLOGY: A total of 90 patients underwent PD for various periampullary diseases. Of these, 52 patients received a conventional PD (cPD), while 38 patients underwent a tMPDe. Surgical outcomes were compared between the two study groups. RESULTS: Operative time was equivalent in the two groups; however, the estimated blood loss (cPD, 1360 ml; tMPDe, 995 ml; median, P = 0.026) and blood transfusion rate (cPD, 63%; tMPDe, 31% ; P = 0.001) were significantly decreased in tMPDe. Morbidity had no significant difference between cPD and tMPDe, and tMPDe showed no characteristic complications. With regard to oncological aspects, tMPDe was superior to cPD. Risk factors analysis revealed the operative time (P = 0.003), estimated blood loss (P < 0.001), and blood transfusion (P < 0.001) to be significant predictive risk factors for postoperative morbidity but not tMPDe procedure (P = 0.794). CONCLUSIONS: tMPDe is safe and superior to cPD because it is a bloodless operation with a good oncological outcome: We concluded that tMPDe should be adaptable to various periampullary diseases, including benign and low-grade malignant disorders.

Prior oral exposure to environmental immunosuppressive chemicals methoxychlor, parathion, or piperonyl butoxide aggravates allergic airway inflammation in NC/Nga mice.

BACKGROUND: Immunosuppressive environmental chemicals may increase the potency of allergens and thereby play a role in the development of respiratory tract allergies, such as allergic rhinitis and asthma. OBJECTIVES: We investigated the association between environmental immunosuppressive chemicals and the allergic airway inflammation development. METHODS: We used a mouse model of ovalbumin (OVA)-induced allergic airway inflammation. NC/Nga mice were exposed orally to pesticides parathion (an organophosphate compound) or methoxychlor (an organochlorine compound), or to an insecticide synergist piperonyl butoxide, prior to OVA intraperitoneal sensitization and inhalation challenge. We assessed serum IgE levels, B-cell counts, cytokine production, IgE production in hilar lymph nodes, eosinophil counts, chemokine levels in bronchoalveolar lavage fluid, and cytokine gene expression in the lung. RESULTS: Exposure to environmental immunosuppressive chemicals markedly increased serum IgE - IgE-positive B-cells, IgE and cytokines in lymph nodes - eosinophils and chemokines in BALF - IL-10a and IL-17 in the lung. CONCLUSIONS: Allergic airway inflammation can be aggravated by prior exposure to immunosuppressive environmental chemicals.

Distal pancreatectomy utilizing a flexible stapler closure eliminates the risk of pancreas-related factors for postoperative pancreatic fistula.

OBJECTIVES: To identify the risk factors for clinically relevant pancreatic fistula after distal pancreatectomy with a flexible cartridge stapler, TL60. METHODS: Forty consecutive patients who underwent a distal pancreatectomy by the TL60 stapler were retrospectively reviewed in association with postoperative complications. RESULTS: The overall morbidity rate was 43% (17 patients), and mortality was null. Pancreatic fistula was the most frequent postoperative complication, seen in 11 patients (27.5%): grade A in 4 (10%) and grade B in 7 (17.5%). No grade C pancreatic fistula was observed. Univariate analyses of risk factors demonstrated that pancreas-related factors, including diabetes mellitus, thickness and texture of the pancreatic parenchyma, transection line for the pancreas, pancreatic duct ligation, and use of artificial patches had no impact on the occurrence of pancreatic fistula. A multivariable logistic regression analysis identified operative time (≥ 300 min) as the only notable predictor of clinically relevant pancreatic fistula (odds ratio = 3.253, 95% confidence interval 1.739-5.752; p = 0.031). CONCLUSION: Distal pancreatectomy with the use of the TL60 stapler eliminated the risk of pancreas-related factors for the occurrence of clinically relevant pancreatic fistula.

Appraisal of a total meso-pancreatoduodenum excision with pancreaticoduodenectomy for pancreatic head carcinoma.

BACKGROUND: The most significant prognostic factors for pancreatic head carcinoma (PHC) with pancreaticoduodenectomy (PD) are the resection margin and lymph node status. The curative surgical margin (R0) and complete clearance of regional lymph nodes contribute to the improvement of survival. To reduce microscopic residual tumor resection (R1) and achieve a complete lymphadenectomy around the superior mesenteric artery (SMA) when performing a PD for PHC, we propose a new concept of a total excision of the "meso-pancreatoduodenum." which consists of a cluster of the soft connective tissue along the inferior pancreaticoduodenal artery and the first jejunal artery. METHODS: A total of 39 consecutive patients underwent a PD for PHC between May 2006 and August 2011 at Shimane University Hospital. Twenty-five patients received a standard PD (sPD), while 14 cases underwent a total meso-pancreatoduodenum excision (tMPDe) with PD. RESULTS: The tMPDe procedure was performed safely without any intraoperative complications. The total number of lymph nodes dissected was 18 (median, range: 5-40) in the sPD and 26 (median, range: 13-50) in the tMPDe (p = 0.027). R0 resection was accomplished in 60% and 93% of patients with the sPD and tMPDe, respectively, resulting in a significant decrease in the R1 rate in the tMPDe (7%) compared to that in the sPD (40%) (p = 0.019). No loco-regional recurrence was found around the SMA in the tMPDe patients. CONCLUSION: Our surgical technique, tMPDe, is safe and more radical when performing a PD and should be adopted when performing pancreatic surgery as a pathological cure for pancreatic head carcinoma.

Prior or coinstantaneous oral exposure to environmental immunosuppressive agents aggravates mite allergen-induced atopic dermatitis-like immunoreaction in NC/Nga mice.

BACKGROUND: Immunosuppressive environmental chemicals may increase the potency of allergens and thereby play a role in the development of allergic diseases such as allergic rhinitis, asthma and atopic dermatitis (AD). OBJECTIVES: This study's primary objective was to examine the mechanisms behind the development of allergic diseases and immunosuppression induced by some environmental chemicals. We focused on the aggravation of AD by the organophosphorus pesticide O,O-diethyl-O-4-nitro-phenylthiophosphate (parathion) and the organochlorine pesticide 1,1,1-trichloro-2,2-bis(4-methoxyphenyl)ethane (methoxychlor), in NC/Nga mice sensitized with extract of Dermatophagoides farinae (Df). METHODS: NC/Nga mice were exposed orally to parathion or methoxychlor prior or coinstantaneous with sensitization with Df. The mice were subsequently challenged with Df. One day after the last challenge with Df, we analyzed dermatitis severity and expression of genes in the ear auricle, immunoglobulin (Ig) E and IgG(2a) levels in serum, and in auricular lymph nodes, T- or B-cell numbers and cytokine production. RESULTS: Prior exposure to parathion or methoxychlor induced marked increases in the following: dermatitis severity and gene expression in the ear auricle, IgE and IgG(2a) levels in serum, expression of surface antigens on helper T-cell and IgE-positive B-cell, production of Th1 and Th2 cytokines, and production of IgE in auricular lymph-node cells. In contrast, coinstantaneous exposure to parathion or methoxychlor yielded, at most, small but significant decreases in all parameters. CONCLUSIONS: Our results indicate that atopic dermatitis can be aggravated by prior exposure to immunosuppressive environmental chemicals.

Detection of thymocytes apoptosis in mice induced by organochlorine pesticides methoxychlor.

The thymus has long been known to be vulnerable to atrophy when exposed to variety of stimuli, including hormones, immunosuppressive pharmaceuticals, and environmental chemicals. The organochlorine pesticide methoxychlor (MXC) is an immunosuppressive agent thought to affect thymic atrophy by inducing apoptosis of thymocyte T cells. We sought to develop an experimental protocol to detect in vivo thymocyte apoptosis induced by MXC in Balb/c mice. We treated the mice with 150-400 mg/kg MXC. We then measured thymus weight, cell counts, caspase activity (3/7, 8, and 9), annexin V labeling of phosphatidylserine (PS) and DNA fragmentation. In MXC-treated mice we observed decreases in thymus weight and cell counts and increases in caspase activity (3/7, 8, and 9), annexin V PS labeling and DNA fragmentation. These results suggest that MXC induces thymic atrophy caused by thymocyte apoptosis, and that our protocol may be useful for detecting in vivo thymocyte apoptosis induced by environmental chemicals in short-time.

Pathology of lethal peripartum broad ligament haematoma in 31 Thoroughbred mares.

REASONS FOR PERFORMING STUDY: Broad ligament haemorrhage in peripartum mares is a life-threatening disease and there are few reports on the aetiology and pathogenesis of broad ligament haematoma. OBJECTIVES: To obtain information regarding the sites for the early diagnosis and pathogenesis of broad ligament haematoma of mares. METHODS: Thirty-one mares that died of broad ligament haematoma peripartum were examined pathologically for bleeding sites. The arterial distribution of 5 young mares with several parities served as negative controls. RESULTS: Age and/or multiparity were the predisposing factors for the disease. Arterial injuries were most commonly observed in the uterine artery (24 of 31 mares). Among these, the proximal uterine artery that lies within 15 cm of the bifurcation of the iliac artery was the most frequent site for rupture (18 mares). The lesions occurred preferentially at the bifurcations, lateral part of curvatures and abrupt flexures of the artery. The morphology of the injuries was classified into 3 types: ruptures with and without longitudinal fissures, and transections. Histologically, the arterial wall adjacent to the rupture showed atrophy of smooth muscle cells with fibrosis of the tunica media and disruption and/or calcification of the internal elastic lamina. CONCLUSIONS: Arterial injuries that led to broad ligament haematoma in peripartum mares occurred most frequently in the proximal uterine artery, and atrophy of smooth muscle cells with fibrosis of the arterial wall was as one of the predisposing factors in aged and multiparous mares. POTENTIAL RELEVANCE: Monitoring small aneurysms, mural tearing, medial fibrosis at the proximal uterine artery by transrectal echography could provide useful information for the early diagnosis and possible prevention of broad ligament haematoma of peripartum mares.

Helicobacter bilis colonization of the biliary system in patients with pancreaticobiliary maljunction.

BACKGROUND: Helicobacter bilis is considered to be a causative factor in the pathogenesis of biliary cancer. This study investigated the prevalence of H. bilis colonization of the biliary system of patients with pancreaticobiliary maljunction (PBM). METHODS: Bile juice and biliary tissue samples were collected from 17 patients with PBM and 27 controls who had benign biliary disease without PBM. DNA extracted from each biliary sample was subjected to polymerase chain reaction (PCR) analysis for H. bilis and Helicobacter pylori. RESULTS: PCR assays revealed that 12 of the 17 patients with PBM were positive for H. bilis DNA, compared with eight of 27 patients without PBM (P = 0.009). Among patients with PBM, H. bilis DNA was identified in six of eight children, including a 2-month-old infant, and in six of nine adults. The high prevalence of H. bilis DNA in the biliary system of patients with PBM was independent of age, sex, common bile duct dilatation, configuration of the pancreatic and bile ducts, and amylase activity in bile. CONCLUSION: H. bilis colonization of the biliary system is extremely common in patients with PBM. This may point to a role in the pathogenesis of biliary cancer.

Unusual cutaneous features of syphilis in patients positive for human immunodeficiency virus.

Dermatologists commonly find it difficult to diagnose syphilis, because of its protean clinical features. In cases of co-infection with human immunodeficiency virus (HIV) syphilis may present particularly unusual clinical features, further confounding the diagnosis. We report two cases of syphilis/HIV co-infection in Japanese patients showing uncommon skin features that made the diagnosis of syphilis difficult. These cases underline the need for dermatologists to be more aware of atypical cutaneous features of syphilis in patients positive for HIV.