Source Analysis and Effective Control of a COVID-19 Outbreak in a University Teaching Hospital during a Period of Increasing Community Prevalence of COVID-19

Background@#South Korea has been experiencing a third wave of coronavirus disease 2019 (COVID-19) since mid-November 2020. Our hospital in Gwangju metropolitan city experienced a healthcare-associated COVID-19 outbreak early in the third wave. The first confirmed COVID-19 patient was a symptomatic neurosurgery resident with high mobility throughout the hospital. We analyzed the transmission routes of nosocomial COVID-19 and discussed infection control strategies. @*Methods@#We retrospectively analyzed the severe acute respiratory syndrome coronavirus 2 reverse transcription-polymerase chain reaction (RT-PCR) testing results according to time point and evaluated transmission routes. @*Results@#Since COVID-19 was first confirmed in a healthcare worker (HCW) on 11/13/2020, we performed RT-PCR tests for all patients and caregivers and four complete enumeration surveys for all HCWs. We detected three clusters of nosocomial spread and several sporadic cases. The first cluster originated from the community outbreak spot, where an asymptomatic HCW visited, which led to a total of 22 cases. The second cluster, which included patient-to-patient transmission, originated from a COVID-19 positive caregiver before diagnosis and the third cluster involved a radiologist and a banker. We took measures to isolate Building 1 of the hospital for 17 days and controlled the outbreak during a period of increasing community COVID-19 prevalence. Universal screening of all inpatients upon admission and resident caregivers was made mandatory and hospital-related employees are now screened monthly. @*Conclusion@#Infection control strategies to prevent the nosocomial transmission of emerging infectious diseases must correspond with community disease prevalence. Our data reinforce the importance of multi-time point surveillance of asymptomatic HCWs and routine surveillance of patients and caregivers during an epidemic.

Source Analysis and Effective Control of a COVID-19 Outbreak in a University Teaching Hospital during a Period of Increasing Community Prevalence of COVID-19

Background@#South Korea has been experiencing a third wave of coronavirus disease 2019 (COVID-19) since mid-November 2020. Our hospital in Gwangju metropolitan city experienced a healthcare-associated COVID-19 outbreak early in the third wave. The first confirmed COVID-19 patient was a symptomatic neurosurgery resident with high mobility throughout the hospital. We analyzed the transmission routes of nosocomial COVID-19 and discussed infection control strategies. @*Methods@#We retrospectively analyzed the severe acute respiratory syndrome coronavirus 2 reverse transcription-polymerase chain reaction (RT-PCR) testing results according to time point and evaluated transmission routes. @*Results@#Since COVID-19 was first confirmed in a healthcare worker (HCW) on 11/13/2020, we performed RT-PCR tests for all patients and caregivers and four complete enumeration surveys for all HCWs. We detected three clusters of nosocomial spread and several sporadic cases. The first cluster originated from the community outbreak spot, where an asymptomatic HCW visited, which led to a total of 22 cases. The second cluster, which included patient-to-patient transmission, originated from a COVID-19 positive caregiver before diagnosis and the third cluster involved a radiologist and a banker. We took measures to isolate Building 1 of the hospital for 17 days and controlled the outbreak during a period of increasing community COVID-19 prevalence. Universal screening of all inpatients upon admission and resident caregivers was made mandatory and hospital-related employees are now screened monthly. @*Conclusion@#Infection control strategies to prevent the nosocomial transmission of emerging infectious diseases must correspond with community disease prevalence. Our data reinforce the importance of multi-time point surveillance of asymptomatic HCWs and routine surveillance of patients and caregivers during an epidemic.

Performance Evaluation of VITEK MS for the Identification of a Wide Spectrum of Clinically Relevant Filamentous Fungi Using a Korean Collection

The correct identification of filamentous fungi is challenging. We evaluated the performance of the VITEK MS v3.0 system (bioMérieux, Marcy-l’Étoile, France) for the identification of a wide spectrum of clinically relevant filamentous fungi using a Korean collection. Strains that were added to the upgraded v3.2 database were additionally identified by the VITEK MS v3.2 system. Of the 105 tested isolates, including 37 Aspergillus (nine species), 41 dermatophytes (seven species), and 27 other molds (17 species), 43 (41.0%) showed “no identification” or “multiple species identification” results at the initial VITEK MS testing; these isolates were retested using the same method. Compared with sequence-based identification, the correct identification rate using VITEK MS for Aspergillus, dermatophytes, other molds, and total mold isolates was 67.6%, 56.1%, 48.1%, and 58.1% at the initial testing and 94.6%, 78.0%, 55.6%, and 78.1% with retesting, respectively. Following retesting, 19 (18.1%) and two (1.9%) isolates showed “no identification” and “misidentification” results, respectively. VITEK MS reliably identified various filamentous fungi recovered in Korea, with a very low rate of misidentification

Air and Environmental Contamination Caused by COVID-19 Patients: a MultiCenter Study

Background@#The purpose of this study was to determine the extent of air and surface contamination of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in four health care facilities with hospitalized coronavirus disease 2019 (COVID-19) patients. @*Methods@#We investigated air and environmental contamination in the rooms of eight COVID-19 patients in four hospitals. Some patients were in negative-pressure rooms, and others were not. None had undergone aerosol-generating procedures. On days 0, 3, 5, and 7 of hospitalization, the surfaces in the rooms and anterooms were swabbed, and air samples were collected 2 m from the patient and from the anterooms. @*Results@#All 52 air samples were negative for SARS-CoV-2 RNA. Widespread surface contamination of SARS-CoV-2 RNA was observed. In total, 89 of 320 (27%) environmental surface samples were positive for SARS-CoV-2 RNA. Surface contamination of SARSCoV-2 RNA was common in rooms without surface disinfection and in rooms sprayed with disinfectant twice a day. However, SARS-CoV-2 RNA was not detected in a room cleaned with disinfectant wipes on a regular basis. @*Conclusion@#Our data suggest that remote (> 2 m) airborne transmission of SARS-CoV-2 from hospitalized COVID-19 patients is uncommon when aerosol-generating procedures have not been performed. Surface contamination was widespread, except in a room routinely cleaned with disinfectant wipes.

Viral Load Kinetics of SARS-CoV-2Infection in Saliva in Korean Patients:a Prospective Multi-center Comparative Study

Background@#This study was performed to compare the viral load and kinetics of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in saliva with those in standard nasopharyngeal/oropharyngeal (NP/OP) swabs. @*Methods@#Fifteen patients with SARS-CoV-2 infection from four hospitals were prospectively enrolled and matched samples of nasopharyngeal/oropharyngeal swabs and saliva were collected at Day 1 of admission and every other day till consequently negative for two times. Real-time reverse transcription polymerase chain reaction (rRT-PCR) was performed to detect the envelope (E) and RNA-dependent RNA polymerase (RdRP) genes. @*Results@#The cycle threshold values of saliva were comparable to those of NP/OP swabs overall (P = 0.720, Mann–Whitney U test). However, the overall sensitivity of rRT-PCR using saliva was 64% (34/53), which is lower than the 77% (41/53) using NP/OP swabs. The sensitivity of rRT-PCR using saliva was especially lower in early stage of symptom onset (1–5 days; 8/15; 53%) and in patients who did not have sputum (12/22; 55%). @*Conclusion@#Saliva sample itself is not appropriate for initial diagnosis of coronavirus disease 2019 (COVID-19) to replace NP/OP swabs, especially for the person who does not produce sputum. COVID-19 cannot be excluded when the test using saliva is negative, and it is necessary to retest using NP/OP swabs.

Management of Cyanide Intoxication with Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy / 대한중환자의학회지

Cyanide intoxication results in severe metabolic acidosis and catastrophic prognosis with conventional treatment. Indications of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are expanding to poisoning cases. A 50-year-old male patient arrived in the emergency room due to mental change after ingestion of cyanide as a suicide attempt 30 minutes prior. He was comatose, and brain stem reflexes were absent. Initial laboratory analysis demonstrated severe metabolic acidosis with increased lactic acid of 25 mM/L. Shock and acidosis were not corrected despite a large amount of fluid resuscitation with highdose norepinephrine and continuous renal replacement therapy. We decided to apply ECMO and CRRT to allow time for stabilization of hemodynamic status. After administration of antidote infusion, although the patient had the potential to progress to brain death status, vital signs were improved with correction of acidosis. We considered the evaluation for organ donation. We report a male patient who showed typical cyanide intoxication as lethal metabolic acidosis and cardiac impairment, and the patient recovered after antidote administration during vital organ support through ECMO and CRRT.

Evaluation of Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry-Based VITEK MS System for the Identification of Acinetobacter Species from Blood Cultures: Comparison with VITEK 2 and MicroScan Systems

BACKGROUND: Acinetobacter species are the leading cause of bloodstream infection (BSI), but their correct identification is challenging. We evaluated the matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS)-based VITEK MS (bioMerieux, France), and two automated systems, VITEK 2 (bioMerieux) and MicroScan (Siemens, USA) for identification of Acinetobacter BSI isolates. METHODS: A total of 187 BSI isolates recovered at a university hospital in Korea between 2010 and 2012 were analyzed. The identification results obtained using VITEK MS and two automated systems were compared with those of rpoB sequencing. RESULTS: Of 187 isolates analyzed, 176 were identified to the species level by rpoB sequencing: the Acinetobacter baumannii group (ABG; 101 A. baumannii, 43 A. nosocomialis, 10 A. pittii isolates) was most commonly identified (82.4%), followed by Acinetobacter genomic species 13BJ/14TU (5.3%), A. ursingii (2.1%), A. soli (2.1%), A. bereziniae (1.1%), and A. junii (1.1%). Correct identification rates to the species group (ABG) level or the species level was comparable among the three systems (VITEK MS, 90.3%; VITEK 2, 89.2%; MicroScan, 86.9%). However, VITEK MS generated fewer misidentifications (0.6%) than VITEK 2 (10.8%) and MicroScan (13.1%) (P<0.001). In addition, VITEK MS demonstrated higher specificity (100%) for discrimination between ABG and non-ABG isolates than the other systems (both, 31.8%) (P<0.001). CONCLUSIONS: The VITEK MS system is superior to the VITEK 2 and MicroScan systems for identification of Acinetobacter BSI isolates, with fewer misidentifications and better discrimination between the ABG and non-ABG isolates.

Management of Cyanide Intoxication with Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy / 대한구급학회지

Cyanide intoxication results in severe metabolic acidosis and catastrophic prognosis with conventional treatment. Indications of extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) are expanding to poisoning cases. A 50-year-old male patient arrived in the emergency room due to mental change after ingestion of cyanide as a suicide attempt 30 minutes prior. He was comatose, and brain stem reflexes were absent. Initial laboratory analysis demonstrated severe metabolic acidosis with increased lactic acid of 25 mM/L. Shock and acidosis were not corrected despite a large amount of fluid resuscitation with highdose norepinephrine and continuous renal replacement therapy. We decided to apply ECMO and CRRT to allow time for stabilization of hemodynamic status. After administration of antidote infusion, although the patient had the potential to progress to brain death status, vital signs were improved with correction of acidosis. We considered the evaluation for organ donation. We report a male patient who showed typical cyanide intoxication as lethal metabolic acidosis and cardiac impairment, and the patient recovered after antidote administration during vital organ support through ECMO and CRRT.

Higher Lesion Detection by 3.0T MRI in Patient with Transient Global Amnesia

PURPOSE: Transient global amnesia (TGA) patients were retrospectively reviewed to determine the usefulness of high-field strength MRI in detecting probable ischemic lesions in TGA. MATERIALS AND METHODS: We investigated the lesion detection rate in patients with TGA using 1.5T and 3.0T MRI. Acute probable ischemic lesions were defined as regions of high-signal intensity in diffusion weighted image with corresponding low-signal intensity in apparent diffusion coefficient map. RESULTS: 3.0T MRI showed 11 out of 32 patients with probable ischemic lesions in the hippocampus with mean lesion size of 2.8 +/- 0.6 mm, whereas 1.5T MRI detected no lesion in any of 11 patients. There were no significant differences in clinical characteristics between the groups of 1.5 and 3.0T MRI. CONCLUSION: High-field strength MRI has a higher detection rate of probable ischemic lesions than low-field strength MRI in patients with TGA.

Three Patients With Classic and Atypical Neurodegeneration With Brain Iron Accumulation

Neurodegeneration with brain iron accumulation (NBIA) is a disorder characterized by various mixtures of extrapyramidal, pyramidal or psychiatric abnormalities associated with iron accumulation in the basal ganglia. The mutations in the pantothenate kinase gene (PANK2) were found in approximately two thirds of the patients with NBIA. We report three patients wtih NBIA, and two of them showed mutations in the PANK2 gene.

Lacunar Infarction in Type 2 Diabetes Is Associated with an Elevated Intracranial Arterial Pulsatility Index

PURPOSE: The arterial pulsatility index (PI) is measured by transcranial Doppler ultrasonography (TCD) and is postulated to reflect the vascular resistance distal to the artery being examined. An increased PI of the intracranial artery is often reported with diabetes mellitus (DM), old age, hypertension, intracranial hypertension, vascular dementia, and small artery disease. Microvascular complication of DM, which may contribute to cerebral infarction, involves the small perforating artery and may influence the PI of the proximal artery. MATERIALS AND METHODS: We performed a TCD examination in patients with type 2 DM with acute lacunar infarction (DML, n=35), type 2 DM without cerebral infarction (DMO, n=69), and in control cases with no DM or cerebral infarction (control group, n=41). We then compared the TCD findings among these groups. RESULTS: The PI was significantly higher in the DML and DMO groups than in the control group (1.05, 0.93, 0.73. respectively, for the right middle cerebral artery; 1.04, 0.90, 0.73, respectively, for the left middle cerebral artery; 0.97, 0.89, 0.70, respectively, for the basilar artery). The PI was also significantly higher in the DML group than in the DMO group for both middle cerebral arteries. The flow velocity was comparable among the three groups. CONCLUSION: The elevated PI of the intracranial arteries may reflect diabetic cerebral microvascular complications. The PI measurement using TCD may be a useful predictor of lacunar infarction in type 2 DM patients.

A Case of Adult Polyglucosan Body Disease

Adult polyglucosan body disease (APBD) is a rare neurological disease, characterized by adult onset (fifth to seventh decades), progressive sensorimotor or pure motor peripheral neuropathy, upper motor neuron symptoms, neurogenic bladder, and cognitive impairment. APBD is confirmed by a sural nerve biopsy that shows the widespread presence of polyglucosan bodies in the nerve. We report a 70 year old male patient who exhibited progressive weakness in all extremities and dementia. His electrodiagnostic studies showed sensorimotor polyneuropathy and muscle pathology that consisted of polyglucosan bodies located in small peripheral nerves. This is the first case of APBD reported in Korea.

Retroperitoneal Fibrosis with Inflammatory Aortic Aneurysm Managed by Laparoscopic Ureterolysis and Intraperitonealization of the Ureters / 대한비뇨기과학회지

Inflammatory aortic aneurysm is rare cause of retroperitoneal fibrosis with ureteral obstruction. Although the treatment options for retroperitoneal fibrosis are variable, a surgical procedure is the best choice when this condition is combined with inflammatory aortic aneurysm. We report here on our experience with laparoscopic bilateral ureterolysis and intraperitonealization of the ureters for the patient suffering with retroperitoneal fibrosis that was caused by an inflammatory aortic aneurysm.

The Quantitative 18-fluorodeoxyglucose PET Study in the Differential Diagnosis between Idiopathic Parkinson's Disease and Multiple System Atrophy

BACKGROUND: Overlapping clinical features of idiopathic Parkinson's disease (IPD) and multiple system atrophy (MSA) make it difficult to conduct an accurate differential diagnosis. We performed a quantitative F18- fluorodeoxyglucose PET (FDG PET) and measured the striatal and cerebellar glucose metabolism to evaluate the efficacy of a FDG PET study in the differential diagnosis between IPD and MSA. METHODS: This study included 19 patients with IPD, 28 patients with MSA (MSA-P : MSA-C = 19 : 9) and 12 age matched normal controls. A FDG PET study was performed in all subjects and the original PET image was corrected with the radioactivity curve obtained by repetitive sampling of the radial arterial blood. RESULTS: The measurements of striatal and cerebellar glucose metabolisms of the patients with MSA-P were significantly lower than those of the patients with IPD (P<0.001). However, the measurement of the caudate nucleus provided the most reliable clue for the differential diagnosis between IPD and MSA-P (sensitivity 94.7% and specificity 94.7%). In the patients with MSA-C, the glucose metabolism of the cerebellar vermis (P<0.001), cerebellar cortex (P<0.001) and putamen (P<0.05) was significantly lower than those of the patients with IPD. CONCLUSIONS: Quantitative FDG PET is a useful and reliable method in making a differential diagnosis between IPD and MSA.

Tubularized Incised-plate Urethroplasty: Expanded Use in Primary and Repeat Surgery for Hypospadias / 대한비뇨기과학회지

PURPOSE: Tubularized incised-plate (TIP) urethroplasty has recently been successfully applied to all varieties of hypospadias, and also employed for those with no abundant local skin flap following failure of a hypospadias repair. We evaluated the impact of TIP urethroplasty on primary and repeat hypospadias repairs. MATERIALS AND METHODS: Between January 2000 and December 2002, 17 primary and 6 repeat hypospadias repairs were performed by a one surgeon using TIP procedures. We retrospectively analyzed age at surgery, surgical outcomes and complications following correction of a hypospadias. RESULTS: Of the 17 primary hypospadias repairs, the mean patient age and follow-up period were 10, ranging from 0.8 to 34 years, and 13.8, ranging from 2 to 33 months, respectively. The average urethral plate width was increased after a midline incision from 6.8mm to 14.3mm in length. Early complications developed in 7 patients (41.2%), including 4 fistulas, 2 meatal stenoses and 1 wound infection, while there were 3 cases of complications that had to be corrected (17.6%), including 1 meatal stenosis and 2 fistulas. Of the 6 repeat hypospadias repairs, the mean patient age and follow-up period were 10.7 years ranging from 2 to 21 years, respectively and 12.5, ranging from 2 to 33 months, respectively. Two fistulas (33.3% complication rate) developed following the repeat TIP repairs. CONCLUSIONS: TIP urethroplasty is a versatile operation, which can give excellent functional and cosmetic results in patients requiring primary or revisional hypospadias surgery. However, the TIP procedure should not be indicated in repeat hypospadias surgery if the urethral plate has been resected, or is obviously scarred.

Initial Experience of Retroperitoneal Laparoscopic Radical Nephrectomy for Renal Cell Carcinoma / 대한비뇨기과학회지

PURPOSE: A retroperitoneal laparoscopy, by providing direct access to the retroperitoneal cavity, is useful as an approach to urological surgery. Here, our initial experience of retroperitoneal laparoscopic radical nephrectomies, in 18 consecutive patients with renal cell carcinomas, is reported. MATERIALS AND METHODS: The records of 18 consecutive patients, with renal cell carcinomas, that underwent a retroperitoneal laparoscopic radical nephrectomy between June 2000 and September 2002, were reviewed. RESULTS: The retroperitoneal laparoscopic radical nephrectomies, for the renal cell carcinomas, were successfully performed in all but 3 patients. These 3 were converted to an open technique due to severe adhesion in 1 and bleeding in the other 2. Of the 15 renal cell carcinomas, the final pathological stages were pT1N0M0 in 14 and pT2N0M0 in 1. The mean tumor size and specimen weight were 4.3cm, ranging from 2 to 7.5cm and 258gm, ranging from 203 to 372gm, respectively. The tumors involved the upper pole, the mid pole and the lower pole in 5, 6 and 4 cases, respectively. The mean operative time and estimated blood loss were 195 minutes, ranging from 160 to 260 minutes, and 181.3cc, ranging from 50 to 500cc, respectively. In 4 of the 15 patients, Patient-Controlled Analgesia (PCA) were used for the control of post operative pain, the other 11 required minimal postoperative analgesics. The mean interval to resuming oral intake and hospital stay were 2.3 days, ranging from 2 to 3 days, 5.4 days, ranging from 4 to 7 days, respectively. Complications occurred in 2 patients, and included partial atelectasis in 1 and pulmonary edema in the other. Neither local recurrence nor distant dissemination was observed during the mean follow-up of 13.6 months (range 4 to 25). CONCLUSIONS: A retroperitoneal laparoscopic radical nephrectomy is a safe and effective alternative, to an open radical nephrectomy, in patients with a localized renal cell carcinoma.

Three Cases of Sclerosing Lymphangitis of the Penis / 대한남성과학회지

Sclerosing lymphangitis of the penis is a rare condition involving the distal lymphatics that is characterized by cord-like lesions on the shaft or coronal sulcus. Although the etiology is unknown, its association with mechanical trauma, anatomic variants, or infection has been shown. Clinically, the patient notices a painless, firm, cord-like lesion just proximal to the sulcus. Histologic study reveals hypertrophy and sclerosis of lymphatic vessel walls and, in some cases, thrombus formation within the dilated vessels. Most cases are self-limited, and conservative management is indicated, but surgical excision is warranted for persistently symptomatic lesions. We report three cases of sclerosing lymphangitis of the penis that required treatment by surgical excision.

A Case of Pseudomembraneous Colitis Associated with Ascites / 대한소화기내시경학회지

Antibiotics associated colitis due to Clostridium difficile is a common nosocomial infection associated with significant morbidity. In severe cases, pseudomembraneous colitis may be associated with intraperitoneal fluid accumulation. However, the characteristics of the fluid are seldom described. This case report describes pseudomembraneous colitis patient who was presented with low serum-ascites albumin gradients and lymphocytic ascites, without the evidence of infection, malignancy, or inflammatory peritoneal disease.