Surgical Perspectives on the Updated ASTRO Guideline on Partial Breast Irradiation for Breast Cancer.

This is an executive summary of the most recent American Society for Radiation Oncology (ASTRO) guidelines on use of partial breast irradiation in early-stage breast cancer.In the conscientious pursuit of "right-sizing" the management of patients with early-stage breast cancer, there has been an emphasis on judicious de-escalation of therapy. A component of this paradigm shift is partial breast irradiation (PBI), an approach characterized by targeted radiation therapy (RT) to lumpectomy cavity margins rather than to the whole breast (i.e., whole breast irradiation [WBI]) after breast conservation surgery (BCS). The American Society for Radiation Oncology (ASTRO) recently completed a revision of its evidence-based guidelines for the application of PBI.1To accomplish this, recent PBI data were reviewed by panel members, including representatives of the American Society for Radiation Oncology (ASTRO), in collaboration with the American Society of Clinical Oncology (ASCO), and the Society of Surgical Oncology (SSO), which provided representatives and peer reviewers. The guideline was approved by the ASTRO Board of Directors and endorsed by the Canadian Association of Radiation Oncology, European Society for Radiotherapy and Oncology, Royal Australian and New Zealand College of Radiologists, and the Society of Surgical Oncology.The recommendations focused on indications for PBI as an alternative to WBI and technical considerations specific to PBI. This editorial provides a summary and comments on the updated ASTRO PBI guidelines, offering insights into the implications of these findings for clinical practice and multidisciplinary decision-making while underscoring technical considerations for optimal incorporation of PBI into patient care.

Microvascular reactivity and endothelial glycocalyx degradation when administering hydroxyethyl starch or crystalloid during off-pump coronary artery bypass graft surgery: a randomised trial.

The infusion of fluids to patients may affect tissue microcirculation and the endothelial glycocalyx. However, the effects of hydroxyethyl starch and crystalloid on endothelial glycocalyx degradation and microvascular reactivity have not been evaluated in detail. We hypothesised that hydroxyethyl starch may cause less endothelial glycocalyx degradation and better microvascular reactivity than that caused by crystalloid. We randomly allocated 120 patients undergoing off-pump coronary artery bypass graft surgery to receive up to 20 ml.kg-1 of either hydroxyethyl starch 670/0.75 or crystalloid for intra-operative fluid resuscitation. Crystalloid was then infused to meet ongoing fluid requirements. During the peri-operative period, vascular occlusion tests were performed to assess microvascular reactivity, and serum syndecan-1 was measured as an index of endothelial glycocalyx degradation. The median (IQR [range]) fluid infused during surgery was significantly less in the hydroxyethyl starch group than the crystalloid group; 2800 (2150-3550 [1400-7300]) vs. 3925 (3100-4725 [1900-6700]) ml, respectively, p < 0.001. Vascular occlusion test parameters, including tissue oxygen saturation, occlusion and recovery slope did not differ significantly between the groups. Peri-operative changes in syndecan-1 were not significantly different between the groups. We conclude that, in patients undergoing off-pump coronary artery bypass graft surgery, compared with crystalloid, the use of hydroxyethyl starch 670/0.75 did not result in significant differences in microvascular reactivity or endothelial glycocalyx degradation.

An effective diagnostic strategy for accurate detection of RhD variants including Asian DEL type in apparently RhD-negative blood donors in Korea.

BACKGROUND AND OBJECTIVES: The purpose of this study was to provide an effective RHD genotyping strategy for the East Asian blood donors. MATERIAL AND METHODS: RhD phenotyping, weak D testing and RhCE phenotyping were performed on 110 samples from members of the RhD-negative club, private organization composed of RhD-negative blood donors, in the GwangJu-Chonnam region of Korea. The RHD promoter, intron 4, and exons 7 and 10 were analysed by real-time PCR. Two nucleotide changes (c.1227 G>A, and c.1222 T>C) in exon 9 were analysed by sequencing. RESULTS: Of 110 RhD-negative club members, 79 (71·8%) showed complete deletion of the RHD gene, 10 (9·1%) showed results consistent with RHD-CE-D hybrid, and 21 (19·1%) showed amplification of RHD promoter, intron 4, and exons 7 and 10. Of the latter group, 16 (14·5%) were in the DEL blood group including c.1227 G>A (N = 14) and c.1222 T>C (N = 2), 2 (1·8%) were weak D, 1(0·9%) was partial D, and 2 (1·8%) were undetermined. The RhD-negative phenotype samples consisted of 58 C-E-c+e+, 19 C-E+c+e+, 3 C-E+c+e-, 21 C+E-c+e-, 6 C+E-c+e+ and 3 C+E-c-e + . Notably, all 58 samples with the C-E-c+e+ phenotype were revealed to have complete deletion of the RHD gene. The C-E-c+e+ phenotype showed 100% positive predictive value for detecting D-negative cases. CONCLUSIONS: RHD genotyping is not required in half of D-negative cases. We suggest here an effective RHD genotyping strategy for accurate detection of RhD variants in apparently RhD-negative blood donors in East Asia.

A multicenter, phase II trial of everolimus in locally advanced or metastatic thyroid cancer of all histologic subtypes.

BACKGROUND: This phase II study investigated the efficacy and safety of everolimus, an inhibitor of mammalian target of rapamycin (mTOR), in locally advanced or metastatic thyroid cancer. PATIENTS AND METHODS: Patients with thyroid cancer of any histology that was resistant or not appropriate for (131)I received everolimus 10 mg daily orally until unacceptable toxicity or disease progression. The primary end point was disease control rate [partial response (PR) + stable response ≥12 weeks]. Secondary end points included response rates, clinical benefit (PD + durable stable disease (SD)], progression-free survival (PFS), overall survival, duration of response, and safety. RESULTS: Thirty-eight of 40 enrolled patients were evaluable for efficacy. The disease control rate was 81% and two (5%) patients achieved objective response; their duration of response was 21+ and 24+ weeks. Stable disease (SD) and progressive disease was reported in 76% and 17% of patients, respectively. Seventeen (45%) patients showed durable SD (≥24 weeks) and clinical benefit was reported in 19 (50%) patients. Median PFS was 47 weeks [95% confidence interval (CI) 14.9-78.5]. Calcitonin, CEA, and thyroglobulin concentrations were ≥50% lower than baseline in three (30%) and four (44%) patients with medullary thyroid cancer and five (33%) patients with PTC, respectively. The most common treatment-related adverse events were mucositis (84%), anorexia (44%), and aspartate transaminase/alanine transaminase elevation (26%). CONCLUSIONS: Everolimus had a limited activity with low response rate in locally advanced or metastatic thyroid cancer. Reasonable clinical benefit rate and safety profile may warrant further investigation. CLINICALTRIALSGOV NUMBER: NCT01164176.

Investigation on the transmission rate of carbapenemase-producing carbapenem-resistant Enterobacterales among exposed persons in a tertiary hospital using whole-genome sequencing.

BACKGROUND: To reduce transmission of carbapenemase-producing carbapenem-resistant Enterobacterales (CP-CRE), screening is recommended for patients sharing rooms with CP-CRE-detected patients and healthcare workers caring for them. AIM: The aim of this study was to investigate the transmission rate of CP-CRE among exposed people in a tertiary hospital using whole-genome sequencing. METHODS: This study was conducted in a 1751-bed tertiary teaching hospital from January 2017 to December 2019. Index patients were defined as those with positive results in CP-CRE tests during hospitalization. When an index patient was detected in a shared room, we performed CRE screening tests for patients whose stay overlapped with an index patient's stay for at least one day. Where a second case was found, healthcare worker contacts were also screened. CP-CRE were confirmed, and the carbapenemase type identified, by PCR. Whole-genome sequencing was used to compare isolates from index and exposed patients. RESULTS: During the study period, 47 index patients were identified, and they had been in contact with 152 patients in shared rooms and 54 healthcare workers. None of the healthcare workers had CRE. Among the 152 exposed patients, four patients had the same type of carbapenemases as their CP-CRE index patients and all of them were KPC. Whole-genome sequencing revealed that three of these four pairs showed genotypic accordance between the index and the exposed. CONCLUSION: The CP-CRE transmission rate among the exposed patients was calculated as 2.0% (= 3/152).

High viremia, prolonged Lamivudine therapy and recurrent hepatocellular carcinoma predict posttransplant hepatitis B recurrence.

Hepatitis B virus (HBV) recurrence following orthotopic liver transplantation (OLT) is generally preventable by prophylaxis with hepatitis B immunoglobulin (HBIG) and lamivudine (LAM). However, HBV recurrence sometimes develops despite prophylaxis. This study assessed posttransplant outcomes and identified predictors of HBV recurrence. We analyzed the outcomes of 209 consecutive patients positive for hepatitis B surface antigen who underwent OLT, who received either combination prophylaxis with HBIG and LAM (89.0%) or HBIG monoprophylaxis (11.0%). The median follow-up was 36.8 months (range, 1.0-84.4). Posttransplant HBV recurrence occurred in 22 patients (10.5%), including 13 patients with drug-resistant mutations. HBV recurrence was observed in six patients after hepatocellular carcinoma (HCC) recurrence. Independent predictors of HBV recurrence were recurrent HCC (p < 0.001), LAM therapy >1.5 years (p = 0.001) and high HBV DNA titers (> or =10(5) copies/mL) at OLT (p = 0.036). In conclusion, high viremia at OLT and prolonged exposure to LAM should be further stressed as main predictors of HBV recurrence.

Association of Antibody-Secreting Cells With Allograft Rejection After Renal Transplantation.

BACKGROUND: Donor-specific antibodies (DSA) are measured at the time of transplantation to predict renal allograft outcome, but pretransplantation DSA are sometimes not adequate to predict antibody-mediated rejection (AMR). We previously developed a flow cytometric assay that could measure the number of antibody-secreting cells (ASCs) instead of DSA. Here, we evaluated the performance of the flow cytometric ASC assay in predicting renal allograft rejection and compared it with that of the enzyme-linked immunospot (ELISpot) assay. METHODS: We enrolled 25 patients who received renal transplantation between May 2017 and August 2017 at Seoul National University Hospital. Mononuclear cells separated from patient peripheral blood obtained on pretransplantation day 1 were incubated with CpG 2006, human CD40L, interleukin-21, and donor or autologous lymphocyte lysates for 6 days. Flow cytometry and ELISpot assay (Mabtech) were performed to measure the ASCs and their association with graft rejection. RESULTS: The number of donor-reactive ASCs, as measured by flow cytometry, was higher in the rejection group than in the nonrejection group (mean ± standard deviation [SD], 3688.9 ± 3875.3 vs 257.9 ± 297.3, P = .014), and no significant difference was observed in the ELISpot assay. Multiple linear regression analysis showed that the number of donor-reactive ASCs measured by flow cytometry was independently and negatively associated with the number of rejection-free days (P = .008, partial R2 = 0.368, adjusted R2 = 0.496). CONCLUSION: After renal transplantation, an increased number of donor-reactive ASCs, as measured by flow cytometry, was associated with allograft rejection. This may be useful to predict renal allograft rejection by measuring the sensitization status of patients who are awaiting renal transplantation.

Low serum concentrations of anti-tuberculosis drugs and determinants of their serum levels.

SETTING: Low serum concentrations of anti-tuberculosis drugs have occasionally been associated with treatment failure. OBJECTIVE: To determine the prevalence of low serum concentrations of anti-tuberculosis drugs and to identify the determinants of drug concentrations. DESIGN: Venous blood was obtained 2 h after drug ingestion, and serum levels of isoniazid (INH), rifampicin (RMP), ethambutol (EMB), pyrazinamide (PZA), acetyl INH and 25-desacetyl RMP were analysed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Patients with human immunodeficiency virus co-infection and gastrointestinal disease or diarrhoea were excluded. RESULTS: Among 69 enrolled TB patients, the prevalence of a low 2 h serum concentration of at least one anti-tuberculosis drug was 46.4%. Prevalences of a low concentration of INH, RMP, EMB or PZA were 15.2%, 23.5%, 22.4% and 4.5%, respectively. By multivariate linear regression analysis, the serum concentrations of INH, RMP and PZA were positively associated with dose per kg of body weight (P < 0.05). Moreover, INH concentration was associated with acetyl INH/INH ratio (beta = -8.588, P < 0.001) and EMB concentration was associated with calculated creatinine clearance (beta = -0.025, P < 0.001). CONCLUSION: Low concentrations of anti-tuberculosis drugs are common, and although the clinical significance of low concentrations remains uncertain, it may be necessary to optimise drug doses by therapeutic drug monitoring, especially in patients with an inadequate clinical response to chemotherapy.

Comparison of Flow-cytometric Antibody Secreting Cell Assay and Mabtech Immunoglobulin ELISpot Assay.

BACKGROUND: The increase of donor-specific antibodies (DSA) after transplantation could be a more important marker than the level of DSA in pre-transplantation sera. The assessment of sensitized cells that can secrete DSA is needed. We developed an assay for antibody-secreting cells (ASCs) measured with the use of flow cytometry and compared it with the Mabtech immunoglobulin (IgG) ELISpot assay. METHODS: Thirteen patients who were awaiting or received organ transplantation and 15 healthy control subjects were included. All subjects were positive for anti-cytomegalovirus (CMV) IgG. Peripheral blood mononuclear cells (PBMCs) were seeded with CpG 2006 (5'-TCGTCGTTTTGTCGTTTTGTCGTT-3'), 500 ng/mL human CD40 ligand, and 50 ng/mL interleukin-21 in complete RPMI media. Eight micrograms of CMV pp28 antigen were added to test wells and compared with nonstimulated PBMCs. After 72 hours, analysis with the use of the human IgG ELISpot kit (Mabtech) and flow cytometry with anti-CD19-PE, CD27-PE-Cy7, CD38-APC, IgG-FITC antibodies was performed. RESULTS: The flow-cytometric ASC assay was moderately correlated with Mabtech IgG ELISpot assay (r = 0.554; P < .001). The ASCs measured by means of flow cytometry were significantly higher in healthy control subjects compared with patients (P < .001). ASCs measured by means of flow cytometry in CMV antigen-stimulated PBMCs were significantly higher compared with nonstimulated PBMCs (P < .001). The IgG-secreting cells measured by means of Mabtech ELISpot assay was not different between healthy control subjects and patients nor between CMV antigen-stimulated and nonstimulated PBMCs. CONCLUSIONS: Flow-cytometric ASC assay can differentiate ASCs for CMV antigen better than Mabtech IgG ELISpot assay. Flow-cytometric ASC assay might be useful for assessing sensitization status in patients awaiting organ transplantation.

Cytokine-release kinetics of platelet-rich plasma according to various activation protocols.

OBJECTIVES: This study was conducted to evaluate the cytokine-release kinetics of platelet-rich plasma (PRP) according to different activation protocols. METHODS: Two manual preparation procedures (single-spin (SS) at 900 g for five minutes; double-spin (DS) at 900 g for five minutes and then 1500 g for 15 minutes) were performed for each of 14 healthy subjects. Both preparations were tested for platelet activation by one of three activation protocols: no activation, activation with calcium (Ca) only, or calcium with a low dose (50 IU per 1 ml PRP) of thrombin. Each preparation was divided into four aliquots and incubated for one hour, 24 hours, 72 hours, and seven days. The cytokine-release kinetics were evaluated by assessing PDGF, TGF, VEGF, FGF, IL-1, and MMP-9 concentrations with bead-based sandwich immunoassay. RESULTS: The concentration of cytokine released from PRP varied over time and was influenced by various activation protocols. Ca-only activation had a significant effect on the DS PRPs (where the VEGF, FGF, and IL-1 concentrations were sustained) while Ca/thrombin activation had effects on both SS and DS PRPs (where the PDGF and VEGF concentrations were sustained and the TGF and FGF concentrations were short). The IL-1 content showed a significant increase with Ca-only or Ca/thrombin activation while these activations did not increase the MMP-9 concentration. CONCLUSION: The SS and DS methods differed in their effect on cytokine release, and this effect varied among the cytokines analysed. In addition, low dose of thrombin/calcium activation increased the overall cytokine release of the PRP preparations over seven days, relative to that with a calcium-only supplement or non-activation.Cite this article: Professor J. H. Oh. Cytokine-release kinetics of platelet-rich plasma according to various activation protocols. Bone Joint Res 2016;5:37-45. doi: 10.1302/2046-3758.52.2000540.

Evaluation of Changes in New Calculated Panel Reactive Antibody Adopting HLA-Cw, DR51/52/53, and DQ Antigens in Koreans.

BACKGROUND: Calculated panel reactive antibody (cPRA) (%) is percentage of donors that would be incompatible with the candidate, based on the candidate's unacceptable HLA antigens. cPRA based on antigen frequencies of HLA-A, B, and DR has been used in Korea. We developed new cPRA including HLA-Cw, DR51/52/53, and DQ. Changes in new-cPRA were evaluated. METHODS: We analyzed the differences between cPRA based on HLA-A, -B, and -DR antigens (old-cPRA) from cPRA based on HLA-A, -B, -Cw, -DR, -DR51/52/53, and -DQ antigens (new-cPRA) on 125 waitlisted candidates for renal transplantation in Seoul National University Hospital. cPRA for unacceptable antigens was calculated according to 3 different cut-off values (MFI <1000, 3000, and 10000 for cPRAw, cPRAm, and cPRAs, respectively). RESULTS: For HLA class I, cPRAw and cPRAm were significantly increased in new-cPRA compared to old-cPRA (median 78.3% vs 71.7%, P < .001; 34.0% vs 23.5%, P = .029, respectively). For HLA class II, cPRAw, cPRAm, and cPRAs were significantly increased in new-cPRA compared to old-cPRA (median 86.8% vs 42.6%; 58.0% vs 0.0%; 0.0% vs 0.0%, P < .001 for all). CONCLUSIONS: cPRA (%) including HLA-Cw, -DR51/52/53, and -DQ showed remarkable increase, especially in HLA class II antigens. The meaning of this should be carefully interpreted through further studies considering clinical outcomes.

Elevated Microsatellite Alterations at Selected Tetranucleotide Repeats (EMAST) and Microsatellite Instability in Patients with Colorectal Cancer and Its Clinical Features.

PURPOSE: Recently, a different type of microsatellite instability (MSI) instability designated 'elevated microsatellite alterations at selected tetranucleotide repeats' (EMAST) has been reported in several neoplasms, but its clinical implications remain unclear. We aimed to determine the relationships among EMAST, MSI and clinicopathologic characteristics, including oncologic outcomes, in colorectal cancer (CRC). MATERIALS AND METHODS: We evaluated 100 sporadic CRC cases subjected to surgery using five markers (MYCL1, D9S242, D20S85, D8S321, and D20S82) for EMAST and the Bethesda panel for MSI status. Immunohistochemical detection of hMSH3, c-erbB2, EGFR and thymidylate synthase was performed. Clinical characteristics and prognostic relevance were assessed. RESULTS: We identified 22 EMAST-positive tumors (22.0%) and 32 MSI-high (MSI-H) tumors (32.0%). EMAST was more frequent in colon cancer than rectal cancer (p=0.033), and associated with MSI-H phenotype (p<0.001), low expression of hMSH3 (p=0.004), and overexpression of thymidylate synthase (p=0.006). Among the 38 MSI-L tumors, only one (4.5%) showed EMAST. Long-term oncologic results in terms of overall and disease-free survival were similar between EMAST and non-EMAST tumors. CONCLUSION: EMAST is more closely related to MSI-H than MSI-L or MSS status. The clinical and molecular characteristics of EMAST were distinct in terms of tumor location, thymidylate synthase expression, MSI status and hMSH3 expression. Our preliminary findings support the utility of EMAST as a new potential classifier in CRC.

Haptoglobin genotypic distribution (including Hp0 allele) and associated serum haptoglobin concentrations in Koreans.

BACKGROUND: Haptoglobin polymorphism is associated with the prevalence of infections, autoimmune diseases, cardiovascular diseases, and other disorders. Congenital haptoglobin deficiency is associated with anaphylactic transfusion reactions in anhaptoglobinaemic patients with antihaptoglobin antibody. AIMS: To investigate haptoglobin genotypic distribution (including the Hp(0) allele) and associated serum haptoglobin concentrations in Koreans. METHODS: Five hundred and nine healthy Korean adults were randomly selected. Two methods were used: haptoglobin genotyping based on a polymerase chain reaction (PCR) system that exploited the structural difference of the Hp(1) and Hp(2 )alleles, and another PCR method that detected haptoglobin gene deletion by amplification of the junctional region of the Hp(0) allele. Serum haptoglobin concentrations were measured by nephelometry. RESULTS: The haptoglobin genotypes of 509 subjects were as follows: Hp(1)Hp(1), 7.1%; Hp(2)Hp(1), 37.7%; Hp(2)Hp(2), 49.3%; Hp(0)Hp(1), 2.2%; Hp(0)Hp(2), 3.5%; Hp(0)Hp(0), 0.2%. The gene frequency of Hp(0) in Koreans was calculated to be 0.031. Significant differences were seen among the concentrations of each haptoglobin genotype (Kruskal-Wallis test). Hp(0)Hp(2), but not Hp(0)Hp(1), was associated with hypohaptoglobinaemia. CONCLUSIONS: PCR methods for differentiating between haptoglobin genotypes, including the Hp(0) allele, may be useful in a broad spectrum of basic studies and clinical examinations.

Low incidence of TEL/AML1 fusion and TEL deletion in Korean childhood acute leukemia by extra-signal fluorescence in situ hybridization.

TEL/AML1 fusion in acute leukemia results from cryptic translocation of chromosome 12 and 21, the presence of which suggests a favorable prognosis. The incidence of TEL/AML1 fusion in B-lineage ALL is approximately 25%, but the incidence in Korea has not yet been reported. To investigate the incidence of TEL/AML1 fusion and TEL deletion, bone marrow specimens from 77 Korean children with newly diagnosed acute leukemia were analyzed by FISH. We applied extra-signal FISH to discriminate a true TEL/AML1 fusion from a false-positive fusion signal. To determine the cut-off value of the TEL/AML1 fusion signal, 20 normal bone marrow specimens and 28 normal peripheral blood specimens were also analyzed. The frequency of patients with TEL/AML1 fusion was 13.3% (4 cases) among 30 B-lineage ALL and 9.5% among 42 ALL. One TEL/AML1 fusion-positive patient was also found among 4 acute biphenotypic leukemias. TEL/AML1 fusion was not found in any samples from patients with T-lineage ALL or AML. The incidence of TEL deletion was 6.7% (2 cases) among 30 B-lineage ALL and 4.8% among 42 ALL. The incidences of TEL/AML1 fusion and TEL deletion in Korean children with acute leukemia appear to be lower than those in other countries, suggesting a racial difference.

Anti-angiotensin type 1 receptor antibodies associated with antibody-mediated rejection in patients without preformed HLA-donor-specific antibody.

INTRODUCTION: Angiotensin II is a peptide hormone involved in the renin-angiotensin system (RAS). Anti-angiotensin receptor 1 (AT1R) antibodies are implicated in stimulating RAS and are suspected to have some adverse impacts on renal transplantation outcome. METHODS: From November 2009 to February 2012, 37 remaining sera from renal transplantation recipients with biopsy-proven antibody-mediated rejection (AMR) (n = 6), acute cellular rejection (ACR) (n = 23), and AMR + ACR (n = 8) without preformed human leukocyte antigeon (HLA) antibodies were tested with anti-AT1R antibody assay. Forty-two control patients without rejection also were analyzed. RESULTS: The frequency of elevated anti-AT1R antibodies was higher in patients with AMR (n = 14) compared to controls (28.6% vs 4.9%, P = .03, OR = 8.0). It was also higher in patients with AMR + ACR (n=8) (37.5% vs 4.9%, P = .03, OR = 12.0). There was no difference in frequencies of elevated anti-AT1R antibody in patients with ACR. CONCLUSION: Anti-AT1R antibodies were suspected to be associated with occurrence of AMR without preformed HLA antibodies in renal transplantation. Further studies in a larger number of patients are needed.

Outbreak among healthy newborns due to a new variant of USA300-related meticillin-resistant Staphylococcus aureus.

BACKGROUND: The prevalence of community-associated meticillin-resistant Staphylococcus aureus (CA-MRSA) is increasing throughout the world and is an important cause of skin and soft tissue infection (SSTI) in children and neonates. AIM: To describe the successful control of an outbreak caused by a new strain of CA-MRSA in a newborn nursery. METHODS: The investigation of the outbreak in July 2012 is reported with the control measures taken. Molecular typing of the MRSA isolates was performed. FINDINGS: An outbreak of SSTI caused by CA-MRSA occurred in a newborn nursery. Six neonates were infected in a one-month period [infection rate: 8.5% (6/71)]. A new variant of CA-MRSA was responsible, which was characterized as USA300-related, Panton-Valentine Leucocidin (PVL) positive, arginine catabolic mobile element (ACME) negative, sequence type 8 (ST8), staphylococcal cassette chromosome mec (SCCmec) type IVa, agr type I and spa type t008. The outbreak among term neonates followed a rapid transmission pattern and was successfully controlled by implementing various outbreak control measures, including universal chlorhexidine bathing. CONCLUSION: This is the first report of a hospital outbreak caused by a USA300-related CA-MRSA clone in Korea. Early recognition and reinforcement of infection control measures are important in decreasing transmission of CA-MRSA in a hospital setting.

The impact of previous tuberculosis history on T-SPOT.TB® interferon-gamma release assay results.

SETTING: Seoul National University Bundang Hospital, a tertiary referral hospital in Korea. OBJECTIVE: To evaluate whether previous tuberculosis (TB) history has a long-term effect on T-SPOT.TB® results after anti-tuberculosis treatment. DESIGN: We retrospectively reviewed 489 adults (age ≥18 years) who underwent T-SPOT.TB as part of their evaluation between January 2008 and July 2009. RESULTS: Among 489 subjects analysed, 369 were finally included. Active TB was diagnosed in 121/369 (32.8%). T-SPOT.TB was positive in 110 (90.9%) active TB patients. Of the 248 subjects without active TB, T-SPOT.TB positivity was significantly different between the 51 patients with a previous TB history and the 197 without (84.3% vs. 26.9%, P < 0.001). The difference in T-SPOT.TB positivity between the 51 non-active TB patients with a TB history and the 121 active TB patients was not statistically significant (84.3% vs. 90.9%, P = 0.208). Among the 51 non-active TB individuals with a TB history, the mean time since anti-tuberculosis treatment was 22.7 years (range 1-59); this had no correlation with total region of difference 1 (RD1) spot-forming cells (r = -0.076, P = 0.597). CONCLUSION: T-SPOT.TB has a limited role in the diagnosis of TB infection in individuals with a previous history of TB.

Real-time polymerase chain reaction in bronchial aspirate for rapid detection of sputum smear-negative tuberculosis.

SETTING: The real-time polymerase chain reaction (RT-PCR) has increasingly been used for the detection of various micro-organisms, including mycobacteria. OBJECTIVE: To determine the role of RT-PCR in confirming the diagnosis of tuberculosis (TB) when acid-fast bacilli (AFB) smear results in sputum samples were not available (i.e., no sputum or negative smear results). DESIGN: We analysed the data of consecutive patients whose bronchial aspirate (BA) was tested for RT-PCR for the diagnosis of TB from January 2006 to April 2008. Computed tomography (CT), bronchoscopy and tissue biopsies were performed in all patients for confirmatory diagnosis, and BA was collected for microbiological analyses and RT-PCR. Final diagnoses were based on microbiological or clinicopathological criteria. RESULTS: Final diagnoses were made in 136 patients, and TB was confirmed in 77 (including 65 culture-positive patients). RT-PCR was positive in 51.9% (40/77) of the confirmed TB patients. More TB patients (20.8%) were detected using RT-PCR than using BA-AFB stain (40 vs. 20, P < 0.001). Of the 77 TB patients, 44 (57.1%) were detected within a few days using a combination of BA-AFB and RT-PCR. CONCLUSION: Real-time RT-PCR of bronchial aspirate seems to be useful for the rapid diagnosis of TB in suspects with smear-negative TB sputum or no sputum.

Serratia marcescens endophthalmitis associated with intravitreal injections of bevacizumab.

PURPOSE: To report two cases of Serratia marcescens endophthalmitis related to presumed aliquot drug contamination, and to determine the incidence of acute endophthalmitis after intravitreal injection of bevacizumab. METHODS: A retrospective chart review of 2020 consecutive intravitreal bevacizumab injection (IVBI) cases at the three affiliated hospitals of Seoul National University (A, B, and C) was carried out between 12 October 2006, and 31 January 2008. Bevacizumab was retrieved multiple times from a single original vial as needed and then discarded on the same day at hospital A and C, or prepared as a single dose aliquot vial at a compounding pharmacy in the hospital B. RESULTS: The incidence of endophthalmitis after IVBI was 2/2020 (0.099%). Two patients receiving IVBI on the same day, but by different surgeons in different sites in hospital B, developed acute endophthalmitis. S. marcescens was isolated from the vitreous sample of the two patients. Molecular typing with pulsed field gel electrophoresis showed that the organisms were of the same strain, which suggested that the drug was contaminated at the pharmacy. CONCLUSIONS: Endophthalmitis is a rare complication after IVBI and can be caused by contaminated aliquot drug. Serratia is one of the causative organisms of acute endophthalmitis, which can have devastating consequences, despite the treatment. A compounding pharmacy in a hospital might not be able to guarantee that aliquoted drug is free of contamination for the IVBI.