Safety and efficacy of pelvic arterial embolization for primary postpartum hemorrhage in hemodynamically stable and hemodynamically unstable patients: Is it "time" for a paradigm change?

BACKGROUND: Pelvic artery embolization (PAE) is an effective and safe technique for treating postpartum hemorrhage (PPH) with hemodynamic stability. However, its use in hemodynamically unstable patients remains controversial. PURPOSE: To determine the safety and efficacy of pelvic arterial embolization (PAE) according to the hemodynamic state of primary postpartum hemorrhage (PPH) patients. METHODS: This cohort study was conducted retrospectively, using data from January 2004 to December 2021, in a resource-rich setting at a tertiary Level 1 trauma academic center. A total of 437 patients were diagnosed with PPH during the study period. Of these 437 patients, 161 with primary PPH who underwent PAE were enrolled in the study. The outcomes assessed included the clinical success rate, mortality, the overall success rate, predictive factors for failed PAE, and time-dependent changes in hemodynamic parameters, such as systolic blood pressure (SBP), heart rate (HR), and shock index (SI). Propensity score (PS) matching analysis was performed to assess the influence of specific variables or conditions on the outcomes. RESULTS: Of the 161 patients who underwent PAE for primary PPH (mean age, 32.9 ± 4.3 [SD]), 85 were retrospectively categorized as having hemodynamic stability (mean age, 32.6 ± 4.1 [SD]), while 76 were categorized as having hemodynamic instability (mean age, 33.3 ± 4.4 [SD]). This study showed PAE for primary PPH had a success rate of 91.9 %, with no significant difference in mortality rates between the groups. The clinical success rate was 98.8 % for patients with hemodynamic stability and 84.2 % for those with hemodynamic instability (p < .001). The overall success rate was 98.8 % for hemodynamic stability and 89.5 % for hemodynamic instability (p = .014). After propensity score matching, the clinical success rate was higher in hemodynamically stable patients than in unstable ones (100 % vs. 86.3 %, p = .013). However, there was no significant difference in the overall success rate (100 % vs. 90.2 %, p = .056). Among the PS-matched population, predictive factors for the failed PAE in primary PPH were hemodynamic instability (adjusted odds ratio [aOR] 21.22, 95 % CI 1.27-355.76; p = .034) and emergency Cesarean delivery with accompanying hemorrhag (aOR 54.00, 95 % CI 11.93-244.56; p = .008). In three groups within a PS-matched population - hemodynamically stable, unstable with successful outcomes, and unstable with unsuccessful outcomes, a generalized linear mixed model (GLMM) analysis for time-dependent changes in hemodynamic parameters revealed a statistically significant difference in SBP, HR, and SI at various time points. CONCLUSION: Pelvic arterial embolization of primary postpartum bleeding in hemodynamic instability has been identified as an alternative, safe, and effective life-saving procedure for multidisciplinary treatment in resource-rich environments even after the baseline characteristics are balanced by the PS matching, suggesting it is a primary care option.

Genomic Surveillance of SARS-CoV-2: Distribution of Clades in the Republic of Korea in 2020.

Since a novel beta-coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first reported in December 2019, there has been a rapid global spread of the virus. Genomic surveillance was conducted on samples isolated from infected individuals to monitor the spread of genetic variants of SARS-CoV-2 in Korea. The Korea Disease Control and Prevention Agency performed whole genome sequencing of SARS-CoV-2 in Korea for 1 year (January 2020 to January 2021). A total of 2,488 SARS-CoV-2 cases were sequenced (including 648 cases from abroad). Initially, the prevalent clades of SARS-CoV-2 were the S and V clades, however, by March 2020, GH clade was the most dominant. Only international travelers were identified as having G or GR clades, and since the first variant 501Y.V1 was identified (from a traveler from the United Kingdom on December 22nd, 2020), a total of 27 variants of 501Y.V1, 501Y.V2, and 484K.V2 have been classified (as of January 25th, 2021). The results in this study indicated that quarantining of travelers entering Korea successfully prevented dissemination of the SARS-CoV-2 variants in Korea.

Factors Associated With Viral Load Kinetics of Middle East Respiratory Syndrome Coronavirus During the 2015 Outbreak in South Korea.

We conducted a retrospective study of Middle East respiratory syndrome coronavirus (MERS-CoV) viral load kinetics using data from patients hospitalized with MERS-CoV infection between 19 May and 20 August 2015. Viral load trajectories were considered over the hospitalization period using 1714 viral load results measured in serial respiratory specimens of 185 patients. The viral load levels were significantly higher among nonsurvivors than among survivors (P = .003). Healthcare workers (P = .001) and nonspreaders (P < .001) had significantly lower viral loads. Viral RNA was present on the day of symptom onset and peaked 4-10 days after symptom onset.

Complete Genome Sequence of a Genotype 2B Rubella Virus Isolated in South Korea in 2015.

The complete genome sequence of the wild-type genotype 2B rubella virus RVi/Busan.KOR/10.15[2B], isolated from a patient in South Korea, was determined. The availability of this sequence will help in understanding the circulation of endemic rubella viruses, as well as their genetic diversity.

Genetic characteristics of mumps viruses isolated in Korea from 2007 to 2012.

Mumps is a vaccine-preventable viral disease. Despite vaccine coverage of >95%, the incidence of mumps has increased in Korea since 2007. This study aimed to genetically characterize mumps virus (MuV) strains that circulated in Korea between 2007 and 2012 to determine the factors underlying mumps outbreaks. MuV was isolated from 175 clinical specimens between 2007 and 2012 in Korea. Upon analysis of the SH gene in Korean mumps virus isolates, three different genotypes were identified: I, H, and F. The MuV genotypes I and H co-circulated in Korea, and eight isolates of Korean genotype F were found within the same time period in 2008. An analysis of HN amino-acid sequence data showed that Korean isolates had no changes in their glycosylation sites. At putative neutralizing epitope sites, the Jeryl-Lynn strain showed 4-5 different amino acid sequences from those observed in Korean isolates. Korean isolates of genotypes I and H shared distinctive point mutations on putative neutralizing epitope positions in each genotype. This report describes the genetic characteristics of MuV strains circulating in Korea and provides information on endemic mumps infections. This information may be important to help prevent mumps and control outbreaks of mumps in Korea. J. Med. Virol. 88:1479-1486, 2016. © 2016 Wiley Periodicals, Inc.

The recent ancestry of Middle East respiratory syndrome coronavirus in Korea has been shaped by recombination.

Middle East respiratory syndrome coronavirus (MERS-CoV) causes severe cases of human respiratory disease. Since 2012, the victims have mainly come from the Middle East countries or sporadically from some other geographical regions seeded by the travelers who visited the Middle East. Such an introduction through travelling led to the emergence of a MERS-CoV outbreak in Korea in May 2015, which caused more than 140 confirmed human cases in less than a month. Using 70 complete genome sequences of MERS-CoV isolates, including the most recent sequences for the Korean and Chinese isolates, we reconstructed the phylogenetic relationships of the complete genome and the individual protein coding regions. The Korean MERS-CoV strain clustered in the previously established Hafr-Al-Batin-1_2013 clade together with two Saudi Arabian and one Chinese strain sampled in 2015. Although these four strains remained monophyletic in the entire protein-coding region, this clade showed different phylogenetic relationships across the genome, indicating a shared unique recombination pattern that is different from previously reported putative recombination strains. Our findings suggest that the recent ancestor of the Korean and its related MERS-CoV strains is characterized by unique mosaic genome pattern that is different from other putative recombinants.

Variations in Spike Glycoprotein Gene of MERS-CoV, South Korea, 2015.

An outbreak of nosocomial infections with Middle East respiratory syndrome coronavirus occurred in South Korea in May 2015. Spike glycoprotein genes of virus strains from South Korea were closely related to those of strains from Riyadh, Saudi Arabia. However, virus strains from South Korea showed strain-specific variations.

Middle East Respiratory Syndrome in 3 Persons, South Korea, 2015.

In May 2015, Middle East respiratory syndrome coronavirus infection was laboratory confirmed in South Korea. Patients were a man who had visited the Middle East, his wife, and a man who shared a hospital room with the index patient. Rapid laboratory confirmation will facilitate subsequent prevention and control for imported cases.

Complete Genome Sequence of Middle East Respiratory Syndrome Coronavirus KOR/KNIH/002_05_2015, Isolated in South Korea.

The full genome sequence of a Middle East respiratory syndrome coronavirus (MERS-CoV) was identified from cultured and isolated in Vero cells. The viral genome sequence has high similarity to 53 human MERS-CoVs, ranging from 99.5% to 99.8% at the nucleotide level.

How Can We Identify the Elimination of Infectious Diseases? Experience From an Active Measles Laboratory Surveillance System in the Republic of Korea.

Global efforts have markedly decreased the disease burden of vaccine-preventable diseases. Many countries have made considerable progress toward the elimination of measles. As elimination is approached, the very low incidence achieved by high vaccination coverage has underscored the need for a sensitive and timely surveillance system. In the Republic of Korea, an active laboratory surveillance system (ALSS) was implemented to supplement the existing passive surveillance system in 2006. The ALSS connects 5 major commercial laboratories and the national measles reference laboratory, where referred samples with positive or equivocal results are retested. Annually, from 2009 to 2013, 3714 suspected cases were detected through the ALSS, an expansion of 8- to 57-fold, compared with only the passive surveillance system. The ALSS, with its sensitivity and timeliness, is a reasonable strategy to supplement the existing measles surveillance system and to help identify the elimination of measles.

Development of Coronary Vasospasm during Adenosine-Stress Myocardial Perfusion CT Imaging.

Adenosine is a short-acting coronary vasodilator, and it is widely used during pharmacological stress myocardial perfusion imaging. It has a well-established safety profile, and most of its side effects are known to be mild and transient. Until now, coronary vasospasm has been rarely reported as a side effect of adenosine during or after adenosine stress test. This study reports a case of coronary vasospasm which was documented on stress myocardial perfusion CT imaging during adenosine stress test.

Resurgence of measles in a country of elimination: interim assessment and current control measures in the Republic of Korea in early 2014.

Since the beginning of 2014, the Republic of Korea has experienced a resurgence of measles cases. Among the 220 cases confirmed as measles during epidemiological weeks 1-20 (December 29, 2013 to May 17, 2014), 10 imported cases were identified. The predominant genotype was B3, which reflects the circulating measles virus in adjacent countries. Even with the verification of measles elimination in March 2014 by the World Health Organization, recent importation has been related to international travel. Targeted control measures have been implemented in addition to proper isolation and patient care. A vigilant surveillance system and high levels of vaccine coverage should be maintained to sustain the measles elimination status.

Value of tumor vessel sign in isolated circumscribed hypervascular abdominopelvic mesenchymal tumors on multidetector computed tomography.

OBJECTIVE: The objective was to determine the usefulness of the tumor vessel sign for differentiating the groups of circumscribed hypervascular abdominopelvic mesenchymal tumors. METHODS: We enrolled a total of 4 groups such as patients with gastrointestinal stromal tumor (GIST) (26 patients), those with paraganglioma (9 patients), those with primary sarcomas (13 patients, excluding those with liposarcoma), and those with desmoid tumor (6 patients). The reviewers evaluated the presence of tumor vessels capable of directly tracing from the tumor margin to the named vessels. RESULTS: Twenty-five of 26 GIST cases, all of the paragangliomas, all of the primary sarcomas, and all of the desmoid tumors showed a positive sign. For the sign confirming GIST, the sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were 96.2%, 100%, 100%, 96.6%, and 98.1%, respectively. The values of the area under the receiver operating characteristic curve have good or excellent diagnostic accuracies. CONCLUSIONS: The presence of the sign is considered to be helpful for differentiating the 4 groups of tumors.

The burden and characteristics of tuberculosis/human immunodeficiency virus (TB/HIV) in South Korea: a study from a population database and a survey.

BACKGROUND: Although, in South Korea, human immunodeficiency virus/acquired immunodeficiency syndrome(HIV/AIDS) keeps increasing and tuberculosis(TB) burden is still significant, there have been few reports on TB/HIV cases. In this study, we investigated the burden and characteristics of TB/HIV patients in South Korea, an area with intermediate burden of TB and a low prevalent area with HIV/AIDS. METHODS: We identified patients with TB and cases with HIV between January 1 2001 and December 31 2005, from nationwide reporting system (TBnet and HIV/AIDS registry) through an electronic record linkage method. A questionnaire survey was also conducted and determined the rate of diagnosis of HIV among TB cases in public health units in 2005. RESULTS: The number of cases with both HIV and TB was 137 (0.07% among 197,562 TB cases) and the newly detected TB/HIV cases per 100,000 population was increasing annually: 2001, 0.025; 2002, 0.031; 2003, 0.025; 2004, 0.071; 2005, 0.095. Males between 20 and 59 years of age accounted for 87.6% of TB/HIV patients. Compared with patients with TB alone, those with TB/HIV had a higher percentage of extrapulmonary TB (8.0% vs 19.0%; p < 0.0001). The standardized prevalence ratio (SPR) of HIV among patients with TB was 18.46 (95% CI, 15.50-21.83). SPR of HIV among male TB patients aged 20-59 and extrapulmonary TB cases was 39.64 (95% CI, 32.87-47.40) and 43.21 (95% CI, 28.22-63.31) respectively. Through a questionnaire survey of public health units, six patients (0.08%) were confirmed as having HIV among 7,871 TB patients in public health centers in 2005, which is similar to the result from the study through nationwide reporting systems. CONCLUSIONS: The prevalence rate of TB/HIV patients is still low but increasing in South Korea. Physicians should consider performing HIV tests among TB patients, especially in higher-risk groups, such as young males with extrapulmonary TB in South Korea.

Epidemiological characteristics of HIV-infected women in the Republic of Korea: A low HIV prevalence country.

Greater than 90 per cent of HIV-infected Koreans are men, and therefore the majority of Korean HIV/AIDS studies reflect the male population. We wished to evaluate the characteristics of HIV infection in women, and to compare our results with those in other countries. To better elucidate HIV infection in Korean women, we examined the characteristics of heterosexual transmission and studied the dynamics of HIV infection in heterosexual couples. We evaluated 479 HIV-infected women who were registered with the government during 1985-2007. The median age at registration and median CD4 cell count were 37 years (N = 479), 362 cells/mm(3) (N = 276), respectively. About 68 per cent had a regular sexual partner and 26 per cent were diagnosed because they had HIV-positive male partners. Eighty-five per cent of women of concordant couples were detected because of previously diagnosed male partners (N = 115). We verified that the majority of HIV-infected women were infected by male sexual partners. These results suggest that early and active detection of HIV-positive men will facilitate earlier detection and prevention in women.

Improvement in survival among HIV-infected individuals in the Republic of Korea: need for an early HIV diagnosis.

BACKGROUND: There is little information describing survival in HIV-infected patients after primary diagnosis in Korea, and changes in survival over time. This study investigated survival times, survival characteristics, and changes in survival after initial HIV diagnosis. Survival was characterized by evaluation of the immune status at primary HIV diagnosis nationwide. METHODS: A total of 5,323 HIV-infected individuals were registered with the government and followed until the end of 2007. Survival following HIV diagnosis was estimated based on epidemiological characteristics. We examined 3,369 individuals with available initial CD4+ T-cell counts within 6 months of HIV diagnosis to estimate survival based on immune status at diagnosis. The association between epidemiological variables and survival times was analyzed with univariate and multivariate Cox's proportional hazards model. RESULTS: Individuals died during the study period (n = 980), and 45% of the individuals died within 6 months of HIV diagnosis. The median survival following HIV diagnosis was 16.7 years. Survival were longer in women, in younger persons, in individuals diagnosed at blood centers, and in individuals diagnosed later in the study period. Survival were shortest in individuals with CD4+ T-cell counts <200 cells/mm3 at HIV diagnosis. These results suggest that early HIV diagnosis in Korea is imperative to increase survival and to promote the quality of life for HIV-infected individuals with governmental support. CONCLUSION: The median survival time of HIV-infected individuals following HIV diagnosis was 16.7 years in Korea. The survival was significantly lower in individuals with CD4+ T-cell counts <200 cells/mm3 at HIV diagnosis and higher by introduction of drugs and development of therapy.

National survey of prevalent HIV strains: limited genetic variation of Korean HIV-1 clade B within the population of Korean men who have sex with men.

The evolution of HIV is the result of an explosive combination of factors-a high rate of mutation, replication dynamics, frequent recombination, and natural selection. To understand the evolution of the distinctive Korean HIV-1 B clade, we investigated the characteristics of the genetic variation of the HIV-1 subtype B env gene within the group of Korean men who have sex with men (MSM). From 1985 to 2005, 700 HIV-1-infected Koreans were sequenced at the V1 to V5 region of the HIV-1 env gene. In the phylogenetic analysis, 560 isolates were identified as HIV-1 subtype B, and 489 of the 560 isolates were HIV-1 Korean clade B. Based on epidemiologic investigation, 249 of 700 HIV-1-infected patients were HIV-1 subtype B-infected MSM. Interestingly, the proportion of the GPGS motif in MSM infected by Koreans was 1.6 times higher than in MSM infected by foreigners, and the genetic expansions of diversity and divergence for HIV-1 subtype B in Korean MSM were 2.1% and 2.5%, respectively. This was much lower than those observed in other countries. Therefore, our findings imply that the HIV strains in this group were closely related. This result may be helpful for understanding the evolution of the distinct HIV-1 Korean B clade.

Inverse relationship between viral load and genotypic resistance mutations in Korean patients with primary HIV type 1 infections.

The transmission of antiretroviral-resistant HIV-1 strains is associated with suboptimal virological responses to initial antiretroviral therapy. However, certain types of resistance mutations are known to be associated with decreased viral fitness, which confers a lower replication capacity than that of the wild-type virus in the absence of antiretroviral drugs. Therefore, we evaluated the relationship between antiretroviral resistance mutations and viral replication in the primary HIV-1 infection (PHI) period. From January 2002 to March 2005, 52 PHI patients were identified in the Republic of Korea. HIV-1 RNA genotyping was performed, and the resistance mutation score was obtained from the HIV Drug Resistance Database of Stanford University. We defined the sum of the average resistance mutation scores (SARMS) for each antiretroviral drug class as a measure of the degree of resistance of any specific strain. The overall mean SARMS was 2.00 +/- 2.74, and the annual mean did not change significantly during the study period. No critical resistance mutation gene was identified in the study group. The SARMS showed a weak negative correlation with the viral load log10 during PHI, but without statistical significance (r = -0.274, p = 0.051). But the mean SARMS of patients with a viral load exceeding 100,000 copies/ml was significantly lower than that of patients with a viral load of less than 100,000 copies/ml (p = 0.03). Evaluation of the potency of antiretroviral resistance revealed a weak negative correlation with viral replication in the PHI period. This could be one reason why the transmission of resistant strains in PHI patients is not increasing significantly despite the widespread use of highly active antiretroviral therapy (HAART).

Molecular investigation of human immunodeficiency virus type 2 subtype a cases in South Korea.

We investigated the molecular characteristics of human immunodeficiency virus type 2 (HIV-2) subtype A isolates to clarify the transmission mode of HIV-2 within Korea. These findings indicated that the viruses from the six patients infected within Korea formed a distinct subcluster in the phylogenetic tree and might have been transmitted from one source.

Nef from a primary isolate of human immunodeficiency virus type 1 lacking the EE(155) region shows decreased ability to down-regulate CD4.

The human immunodeficiency virus (HIV) nef gene encodes a 27 kDa myristoylated cytosolic protein that has an important role in the pathogenesis of AIDS. One function of Nef is the down-regulation of CD4 and MHC class I surface molecules in HIV-infected cells. Nef directly isolated from an infected individual (KS2), who could be defined as a long-term non-progressor, was compared with Nef from a standard laboratory strain, HIV-1 NL4-3. KS2 Nef protein was characterized by its lowered ability to down-regulate CD4, while still maintaining the ability to down-regulate MHC class I. The ability of KS2 Nef to down-regulate CD4 was more prominent when CD4 was measured 2-3 days after transfer of the nef gene to the target cells, and also when the effect was measured in CD4(+)-enriched primary T cells. The amino acid sequence analysis indicated that the most notable feature of KS2 Nef was lack of the two glutamic acids: the EE(155) region. When the EE(155) region was added to KS2 Nef, the CD4 down-regulation ability was increased almost to the level of NL4-3 Nef. Conversely, when the EE(155) region was deleted from NL4-3, its CD4 down-regulation ability was dramatically impaired. These data suggested that the EE(155) region plays an important role(s) in the down-regulation of CD4 by Nef protein and also that primary nef sequences could be very useful in identifying the original biological functions of Nef in vivo.