Safety and efficacy of fluoroscopy-guided urethral catheterization in case of failed blind or cystoscopy-assisted urethral catheterization

This retrospective study evaluated the safety and efficacy of fluoroscopy-guided urethral catheterization in patients who failed blind or cystoscopy-assisted urethral catheterization. We utilized our institutional database between January 2011 and March 2023, and patients with failed blind or cystoscopy-assisted urethral catheterization and subsequent fluoroscopy-guided urethral catheterization were included. A 5-Fr catheter was inserted into the urethral orifice, and the retrograde urethrography (RGU) was acquired. Subsequently, the operator attempted to pass a hydrophilic guidewire to the urethra. If the guidewire and guiding catheter could be successfully passed into the bladder, but the urethral catheter failed pass due to urethral stricture, the operator determined either attempted again with a reduced catheter diameter or performed balloon dilation according to their preference. Finally, an appropriately sized urethral catheter was selected, and an endhole was created using an 18-gauge needle. The catheter was then inserted over the wire to position the tip in the bladder lumen and ballooned to secure it. We reviewed patients' medical histories, the presence of hematuria, and RGU to determine urethral abnormalities. Procedure-related data were assessed. Study enrolled a total of 179 fluoroscopy-guided urethral catheterizations from 149 patients (all males; mean age, 73.3 ± 13.3 years). A total of 225 urethral strictures were confirmed in 141 patients, while eight patients had no strictures. Urethral rupture was confirmed in 62 patients, and hematuria occurred in 34 patients after blind or cystoscopy-assisted urethral catheterization failed. Technical and clinical success rates were 100%, and procedure-related complications were observed in four patients (2.2%). The mean time from request to urethral catheter insertion was 129.7 ± 127.8 min. The mean total fluoroscopy time was 3.5 ± 2.5 min and the mean total DAP was 25.4 ± 25.1 Gy cm2. Balloon dilation was performed in 77 patients. Total procedure time was 9.2 ± 7.6 min, and the mean procedure time without balloon dilation was 7.1 ± 5.7 min. Fluoroscopy-guided urethral catheterization is a safe and efficient alternative in patients where blind or cystoscopy-assisted urethral catheterization has failed or when cystoscopy-urethral catheterization cannot be performed.

Ruxolitinib Improves Immune-Dysregulation Features but not Epigenetic Abnormality in a Patient with STAT1 GOF

PURPOSE

Patients with STAT1 gain-of-function (GOF) mutations often exhibit autoimmune features. The JAK1/2 inhibitor ruxolitinib can be administered to alleviate autoimmune symptoms; however, it is unclear how immune cells are molecularly changed by ruxolitinib treatment. Then, we aimed to investigate the trnscriptional and epigenetic status of immune cells before and after ruxolitinib treatment in a patient with STAT1 GOF.

METHODS

A patient with a heterozygous STAT1 GOF variant (p.Ala267Val), exhibiting autoimmune features, was treated with ruxolitinib, and peripheral blood mononuclear cells (PBMCs) were longitudinally collected. PBMCs were transcriptionally analyzed by single-cell cellular indexing of the transcriptomes and epitopes by sequencing (CITE-seq), and epigenetically analyzed by assay of transposase-accessible chromatin sequencing (ATAC-seq).

RESULTS

CITE-seq analysis revealed that before treatment, the patient's PBMCs exhibited aberrantly activated inflammatory features, especially IFN-related features. In particular, monocytes showed high expression levels of a subset of IFN-stimulated genes (ISGs). Ruxolitinib treatment substantially downregulated aberrantly overexpressed ISGs, and improved autoimmune features. However, epigenetic analysis demonstrated that genetic regions of ISGs-e.g., STAT1, IRF1, MX1, and OAS1-were highly accessible even after ruxolitinib treatment. When ruxolitinib was temporarily discontinued, the patient's autoimmune features were aggravated, which is in line with sustained epigenetic abnormality.

CONCLUSIONS

In a patient with STAT1 GOF, ruxolitinib treatment improved autoimmune features and downregulated aberrantly overexpressed ISGs, but did not correct epigenetic abnormality of ISGs.

Performance evaluation of the SMG HHV-6 Q Real-Time PCR Kit for quantitative detection and differentiation of human herpesvirus 6A and 6B

The aim of this study was to compare the performance of the newly developed SMG HHV-6 Q Real-Time PCR Kit (SMG assay) with the RealStar HHV-6 PCR Kit (RealStar assay). The analytical sensitivity and specificity, linearity, and precision of the SMG assay were evaluated. The clinical performance of the SMG assay was assessed and compared with that of the RealStar assay using 207 clinical specimens (HHV-6A positive, n = 51; HHV-6B positive, n = 64; HHV-6A/B negative, n = 92). The limit of detection of the SMG assay was 2.92 log10 copies/mL for HHV-6A DNA and 2.88 log10 copies/mL for HHV-6B DNA. The linear range was determined to be 3.40-9.00 log10 copies/mL for both viruses. Intra- and inter-assay variability were below 5% at concentrations ranging from 4 to 9 log10 copies/mL. No cross-reactivity was observed with the 25 microorganisms included in the specificity panel. The clinical sensitivity and specificity of the SMG and RealStar assays compared to in-house polymerase chain reaction and sequencing were as follows: SMG assay, 98.0% and 100% for HHV-6A DNA, respectively, and 96.9% and 100% for HHV-6B DNA, respectively; RealStar assay, 98.0% and 100% for HHV-6A DNA, respectively, and 90.6% and 100% for HHV-6B DNA, respectively. The correlation coefficients between viral loads measured by the two assays were 0.948 and 0.975, with mean differences of 0.62 and 0.32 log10 copies/mL for HHV-6A and HHV-6B DNA, respectively. These results demonstrate that the SMG assay is a sensitive and reliable tool for the quantitative detection and differentiation of HHV-6A and HHV-6B DNA.IMPORTANCEQuantitative real-time PCR (qPCR) that can distinguish between HHV-6A and HHV-6B DNA is recommended for diagnosis of active infection. The SMG HHV-6 Q Real-Time PCR Kit (SMG assay) is a newly developed qPCR assay that can differentiate between HHV-6A and HHV-6B DNA; however, little is known about its performance. In this study, we assessed the performance of the SMG assay and compared it with that of a commercially available qPCR assay, the RealStar HHV-6 PCR Kit (RealStar assay). The SMG assay demonstrated excellent analytical sensitivity and specificity, precision, and linearity. Furthermore, the viral loads measured by the SMG assay were highly correlated with those measured by the RealStar assay. Our results suggest that the SMG assay is a useful diagnostic tool for quantitative detection and differentiation of HHV-6A and HHV-6B DNA.

Acupuncture-Induced Abscess in the Retroperitoneal Cavity and Thigh Muscle: A Case Report

Acupuncture is increasingly being used in Asian countries and is generally considered a relatively safe procedure. However, adverse events have been reported consistently. Therefore, clinicians should be aware of the possibility of acupuncture-related complications and should actively treat serious cases. We report a case of an acupuncture-induced large abscess in the retroperitoneal cavity and thigh muscles treated with percutaneous catheter drainage, surgical incision, and drainage.

False-positive Aspergillus galactomannan immunoassay in the glucose component of total parenteral nutrition products

IMPORTANCE

This manuscript describes an occurrence of false-positive GM tests in patients receiving TPN products from a manufacturer who had recently changed the supplier of the glucose component. We describe the clinical presentation of nine false-positive cases and the results of serologic and microbiological investigations of the TPN products suspected of contamination with GM. Attempts to detect GM in parenteral nutrition products were made since the detection of GM in sodium gluconate-containing solutions in 2007, but none of them identified the source of elevated GM indexes in TPN products. However, the present study demonstrated that the glucose component of the TPN products contained a high level of GM antigen, which caused false-positive GM assay results. The source of GM was glucoamylase, which was derived from A. niger in the manufacturing process. Physicians and clinical microbiology laboratories should be aware of this issue to improve interpretation and patient care.

Susceptibility to Fosfomycin and Nitrofurantoin of ESBL-Positive Escherichia coli and Klebsiella pneumoniae Isolated From Urine of Pediatric Patients

BACKGROUND

Pediatric urinary tract infection (UTI) caused by extended-spectrum β-lactamase (ESBL)-positive gram-negative bacilli (GNB) has limited options for oral antibiotic treatment. The purpose of this study was to investigate the susceptibility of ESBL-positive Escherichia coli and Klebsiella pneumoniae isolates from pediatric urine samples to two oral antibiotics (fosfomycin and nitrofurantoin).

METHODS

From November 2020 to April 2022, ESBL-positive E. coli and K. pneumoniae isolates from urine samples were collected at Samsung Medical Center, Seoul, Korea. Patients over 18 years of age or with malignancy were excluded. For repeated isolates from the same patient, only the first isolate was tested. Minimum inhibitory concentrations (MICs) were measured using agar (fosfomycin) or broth (nitrofurantoin) dilution methods. MIC50 and MIC90 were measured for fosfomycin and nitrofurantoin in both E. coli and K. pneumoniae.

RESULTS

There were 117 isolates from 117 patients, with a median age of 7 months (range, 0.0-18.5 years). Among 117 isolates, 92.3% (108/117) were E. coli and 7.7% (9/117) were K. pneumoniae. Isolates from the pediatric intensive care unit (PICU) and general ward (GW) was 11.1% (13/117) and 88.9% (104/117), respectively. Among 108 E. coli isolates, MIC50 and MIC90 for fosfomycin were 0.5 μg/mL and 2 μg/mL, respectively. Fosfomycin susceptibility rate was 97.2% (105/108) with a breakpoint of 128 μg/mL. Fosfomycin susceptibility rate was significantly lower in PICU isolates than in GW isolates (81.8% vs. 99.0%, P = 0.027). For nitrofurantoin, both the MIC50 and MIC90 were 16 μg/mL. Nitrofurantoin susceptibility rate was 96.3% (104/108) with a breakpoint of 64 μg/mL based on Clinical and Laboratory Standards Institute guidelines. Among the nine K. pneumoniae isolates, the MIC50 and MIC90 for fosfomycin was 2 μg/mL and 32 μg/mL, respectively. MIC50 and MIC90 for nitrofurantoin were 64 μg/mL and 128 μg/mL, respectively.

CONCLUSION

For uncomplicated UTI caused by ESBL-positive GNB in Korean children, treatment with fosfomycin and nitrofurantoin for E. coli infections can be considered as an effective oral therapy option.

Loop-mediated isothermal amplification assay for screening congenital cytomegalovirus infection in newborns

Congenital cytomegalovirus (CMV) infection is a common cause of sensorineural hearing loss and neurodevelopmental impairment in newborns. However, congenital CMV infection cannot be diagnosed using samples collected more than 3 weeks after birth because testing after this time cannot distinguish between congenital infection and postnatal infection. Herein, we developed a robust loop-mediated isothermal amplification (LAMP) assay for the large-scale screening of newborns for congenital CMV infection. In contrast to conventional quantitative polymerase chain reaction (qPCR), which detects CMV within a dynamic range of 1.0 × 106 to 1.0 × 102 copies/μL, our quantitative LAMP assay (qLAMP) detects CMV within a dynamic range of 1.1 × 108 to 1.1 × 103 copies/μL. Moreover, the turnaround time for obtaining results following DNA extraction is 90 min in qPCR but only 15 min in qLamp. The colorimetric LAMP assay can also detect CMV down to 1.1 × 103 copies/μL within 30 min, irrespective of the type of heat source. Our LAMP assay can be utilized in central laboratories as an alternative to conventional qPCR for quantitative CMV detection, or for point-of-care testing in low-resource environments, such as developing countries, via colorimetric naked-eye detection. KEY POINTS: • LAMP assay enables large-scale screening of newborns for congenital CMV infection. • LAMP allows colorimetric or quantitative detection of congenital CMV infection. • LAMP assay can be used as a point-of-care testing tool in low-resource environments.

Reversible Ortner's Syndrome as a Presenting Feature of Thyrotoxicosis in an Adolescent: A Rare Case Report

Ortner's or cardiovocal syndrome is hoarseness attributable to left recurrent laryngeal nerve (RLN) palsy associated with mechanical compression of the nerve by pathologically enlarged cardiovascular structures. Ortner's syndrome is a rare condition, and to our knowledge, only a few cases have been reported in Korea. Furthermore, this condition is extremely uncommon in pediatric patients with thyrotoxicosis-related RLN paralysis. We report a case of reversible Ortner's syndrome in an adolescent who presented with secondary pulmonary hypertension related to thyrotoxicosis.

COVID-19 Vaccination Status Among Korean Pediatric Population With Comorbidities

The pediatric population with comorbidities is a high-risk group for severe coronavirus disease 2019 (COVID-19). As of January 2023, the COVID-19 vaccination rate for at least two doses among Korean children 5-11 years is low at 1.1%. We summarized the COVID-19 vaccination status for the pediatric population (5-17 years) with comorbidities through July 2022 using the National Health Insurance Service database. Pediatric patients with comorbidities had higher vaccination rates than the general pediatric population (2.4% vs. 1.1% in 5-11-year-olds [P < 0.001], 76.5% vs. 66.1% in 12-17-year-olds [P < 0.001]). However, there were substantial differences according to comorbidity category, and the 2-dose vaccination rate was lowest among children with immunodeficiency in all age groups (1.1% in 5-11-year-olds, 51.2% in 12-17-year-olds). The COVID-19 vaccination rate among Korean children has remained stagnant at a low proportion despite ongoing outreach. Thus, more proactive strategies are needed alongside continuous surveillance.

The Multifaceted Clinical Characteristics of Congenital Cytomegalovirus Infection: From Pregnancy to Long-Term Outcomes

BACKGROUND

The aim of this study was to capture multifaceted clinical characteristics of congenital cytomegalovirus (CMV) infection from diagnosis to treatment using a multidisciplinary approach including obstetrics, pediatrics, pathology, and otorhinolaryngology-head and neck surgery.

METHODS

This is a retrospective study including 30 consecutive cases of congenital CMV infection that were diagnosed at a single tertiary hospital located in Seoul, Korea from January 2009 to December 2020. Congenital CMV infection was defined as a positive result by polymerase chain reaction from urine, saliva or cerebrospinal fluid or positive CMV IgM from neonatal blood sampled within 3 weeks after birth. All cases were analyzed with respect to whole clinical characteristics from diagnosis to treatment of congenital CMV by a multidisciplinary approach including prenatal sonographic findings, maternal immune status regarding CMV infection, detailed placental pathology, neonatal clinical manifestation, auditory brainstem response test, and antiviral treatment (ganciclovir or valganciclovir). Long-term outcomes including developmental delay and hearing loss were also investigated.

RESULTS

The total number of births during the study period in our institution was 19,385, with the prevalence of congenital infection estimated to be 0.15%. Among 30 cases of congenital CMV, the median gestational age at delivery was 32.2 weeks [range, 22.6-40.0] and 66.7% of these infants were delivered preterm at less than 37 weeks. Suspected fetal growth restriction was the most common prenatal ultrasound finding (50%) followed by ventriculomegaly (17.9%) and abnormal placenta (17.9%), defined as thick placenta with calcification. No abnormal findings on ultrasound examination were observed in one-third of births. Maternal CMV serology tests were conducted in only 8 cases, and one case each of positive and equivocal IgM were found. The most common placental pathologic findings were chronic villitis (66.7%) and calcification (63.0%), whereas viral inclusions were identified in only 22.2%. The most common neonatal manifestations were jaundice (58.6%) followed by elevation of aspartate aminotransferase (55.2%) and thrombocytopenia (51.7%). After excluding cases for which long-term outcomes were unavailable due to death (n = 4) or subsequent follow up loss (n = 3), developmental delay was confirmed in 43.5% of infants (10/23), and hearing loss was confirmed in 42.9% (9/21) during the follow-up period. In our cohort, 56.7% (17/30) of neonates were treated for congenital CMV with ganciclovir or valganciclovir.

CONCLUSION

Our data show that prenatal findings including maternal serologic tests and ultrasound have limited ability to detect congenital CMV in Korea. Given that CMV is associated with high rates of developmental delay and hearing loss in infants, there is an urgent need to develop specific strategies for the definite diagnosis of congenital CMV infection during the perinatal period by a multidisciplinary approach to decrease the risks of neurologic impairment and hearing loss through early antiviral treatment.

[Delayed Bilateral Common Femoral Pseudoaneurysm after Percutaneous Access with Interventional Management: A Case Report]

Common femoral artery pseudoaneurysm is a potentially serious complication of peripheral angiography. There have been few prior reports of simultaneous pseudoaneurysm in both common femoral arteries after percutaneous access. Here we report the case of a 58-year-old male patient who presented with phlegmon or abscess a few days after bilateral femoral access, after which newly developed bilateral femoral pseudoaneurysm with wide neck was observed on CT angiography 2 months after infection treatment. Because the patient refused surgery for pseudoaneurysm, a stent-graft was inserted in the left side, and percutaneous thrombin injection under US guidance with balloon occlusion was performed for the right side. Most pseudoaneurysms occur immediately after the causative procedure. However, there have been some cases in which pseudoaneurysms may occur several weeks or months later; it is therefore necessary to check the risk factors and to carefully observe the hemostasis site.

[Comparison of True and Virtual Non-Contrast Images of Liver Obtained with Single-Source Twin Beam and Dual-Source Dual-Energy CT]

PURPOSE

To assess the magnitude of differences between attenuation values of the true non-contrast image (TNC) and virtual non-contrast image (VNC) derived from twin-beam dual-energy CT (tbDECT) and dual-source DECT (dsDECT).

MATERIALS AND METHODS

This retrospective study included 62 patients who underwent liver dynamic DECT with tbDECT (n = 32) or dsDECT (n = 30). Arterial VNC (AVNC), portal VNC (PVNC), and delayed VNC (DVNC) were reconstructed using multiphasic DECT. Attenuation values of multiple intra-abdominal organs (n = 11) on TNCs were subsequently compared to those on multiphasic VNCs. Further, we investigated the percentage of cases with an absolute difference between TNC and VNC of ≤ 10 Hounsfield units (HU).

RESULTS

For the mean attenuation values of TNC and VNC, 33 items for each DECT were compared according to the multiphasic VNCs and organs. More than half of the comparison items for each DECT showed significant differences (tbDECT 17/33; dsDECT 19/33; Bonferroni correction p < 0.0167). The percentage of cases with an absolute difference ≤ 10 HU was 56.7%, 69.2%, and 78.6% in AVNC, PVNC, and DVNC in tbDECT, respectively, and 70.5%, 78%, and 78% in dsDECT, respectively.

CONCLUSION

VNCs derived from the two DECTs were insufficient to replace TNCs because of the considerable difference in attenuation values.

1326. Mupirocin Resistance in Staphylococcus aureus in Pediatric Patients for Ten Years

Background

Mupirocin has been recommended for decolonization in methicillin-resistant Staphylococcus aureus (MRSA) carriers for recurrent skin and soft tissue infections and treatment for impetigo. However, the indiscriminate use of mupirocin causes mupirocin resistance, associated with decolonization failure. The aim of the study was to investigate the epidemiology of mupirocin resistance and to identify clinical characteristics among children in a single center.

Methods

From January 2011 to October 2020, we retrospectively analyzed the epidemiology of antibiotic resistance and clinical characteristics of pediatric patients under 19 years old in whom S. aureus was firstly isolated at any body site.

Results

Of the 3,414 S. aureus isolates, 46% (1569/3414) were methicillin-resistant, and 20.3% (692/3414) were mupirocin resistant. Among MRSA, Mupirocin-resistant (MupR) was 22.6% (354/1569), and among methicillin-sensitive S. aureus (MSSA), MupR was 18.3% (338/1845) (P< 0.001). The median age of MupR MRSA patients was 0.14 years (interquartile range 0.04-0.79), and the median age of MupR MSSA patients was 5.0 years (interquartile range 2.0-8.1) (P=0.000). Of 692 MupR S. aureus, 94.2% (652/692) were mainly detected in the skin. MupR MRSA was most frequently isolated in the neonatal intensive care unit (40.1%, 142/354), but MupR MSSA was most frequently isolated in the outpatient setting (81.4%, 275/338) (P< 0.001). Of these, 43% (119/275) patients were diagnosed with atopic dermatitis. By age, mupR MRSA was the more commonly isolated in infants younger than one year (77.4%, 274/354), and MupR MSSA was more commonly isolated in children older than three years old (65.4%, 221/338) (P< 0.001). The frequency of MupR MRSA and MSSA showed an increase in trend over time (P< 0.001). Among other topical agents, 6.5% (102/1569) of MRSA was resistant to fusidic acid.

Conclusion

As mupirocin resistance gradually increases, a test for mupirocin susceptibility should be performed before applying the skin lesions or decolonization for MRSA. In addition, clinicians should carefully prescribe mupirocin to prevent the development of MupR S. aureus.

Disclosures

Yae-Jean Kim, MD, PhD, Janssen: Grant/Research Support|Korean Society of Pediatric Infectious Diseases: Grant/Research Support|Ministry of Trade, Industry and Energy: Grant/Research Support|MSD: Grant/Research Support.

2191. Children with severe human rhinovirus lower respiratory tract infection

Background

Human rhinovirus (HRV) infection can also cause lower respiratory tract infections (LRTIs). We aimed to investigate the proportion and characteristics of severe HRV infection among children under 5 years who were hospitalized due to HRV LRTI.

Methods

The medical records were reviewed retrospectively in patients hospitalized caused by HRV LRTI from January 1, 2016 to December 31, 2020, at Samsung Medical Center, Seoul, Korea. Patients who were older than 90 days and younger than 5 years old were included. Patients with co-infection of other respiratory viruses or bacteria were excluded. Patients with cancer were excluded.

Severe HRV LRTI was defined as the following: need for high flow oxygenation, mechanical ventilation, or intensive care unit (ICU) admission.

Results

A total of 116 cases were identified. The median age was 17 months (range, 3-56 months), and their median hospital days were four days (range, 2-31 days). Of 116 cases, 18 cases (15.5%) showed a severe course. The median age was younger in severe group compared to non-severe group (9.5 months vs. 19.5 months, p=0.001). In 18 patients with severe HRV LRTI, 11 (11/18, 61%) had underlying diseases; bronchopulmonary dysplasia and bronchiolitis obliterans accounted for the largest proportion (7/11, 63.6%). Six patients (6/18, 33.3%) required mechanical ventilation. Of note, there were seven previously healthy children (7/18, 38.9%) were diagnosed with severe HRV LRTI. Of those seven, three were diagnosed with asthma later during follow-up.

When 116 cases were divided into previously healthy (n=61) and underlying disease (n=55) groups, severe course of HRV LRTI was observed in 11% and 20%, respectively (p=0.205).

There was no fatal case.

Conclusion

HRV can cause severe LRTI in certain pediatric patient, especially with underlying diseases and young-aged children. One out of ten hospitalized children even without previously diagnosed underlying diseases, showed severe course of HRV LRTI.

Disclosures

Doo Ri Kim, MD, Korean Society of Pediatric Infectious Diseases: Grant/Research Support Yae-Jean Kim, MD, PhD, Janssen: Grant/Research Support|Korean Society of Pediatric Infectious Diseases: Grant/Research Support|Ministry of Trade, Industry and Energy: Grant/Research Support|MSD: Grant/Research Support.

Effectiveness of ultrasound-guided percutaneous transhepatic biliary drainage to reduce radiation exposure: A single-center experience

Percutaneous transhepatic biliary drainage (PTBD) has been an effective treatment to access the biliary tree, especially in case of endoscopically inaccessible biliary tree. In general, PTBD techniques are divided into two methods: fluoroscopy-guided PTBD and ultrasound (US)-guided PTBD. This study aimed to evaluate the effectiveness of US-guided PTBD, focusing on radiation exposure according to intrahepatic duct (IHD) dilatation degree, differences between right- and left-sided approaches and differences between benign and malignant biliary stenosis/obstruction. We evaluated technical success, clinical success, procedural data (the number of liver capsule punctures, procedural time, fluoroscopy time and radiation dose), and procedure-related complications. During the study period, a total of 123 patients with biliary stenosis/obstruction or bile leakage were initially eligible. We excluded 76 patients treated with only ERCP or initially treated with ERCP followed underwent PTBD insertion. Finally, a total of 50 procedures were performed in 47 patients. Of the 47 patients, 8 patients had anatomical alteration due to previous surgery, 6 patients refused ERCP, and 3 patients failed ERCP. For the remaining 30 patients, PTBD was performed on weekend or at night, 11 of whom had poor general condition, 10 patients underwent ERCP 3 to 4 days later after PTBD insertion, 6 patients improved after PTBD insertion without ERCP, 1 patient died, and 1 patient was referred to other hospital. Remaining 1 patient underwent surgery due to Mirizzi syndrome. All procedures were performed by two interventional radiologists. Technical success rate was 100%, clinical success was 94%, and the complication rate was 10%. Fluoroscopy time and the reported radiation dose were significantly lower in patients with dilated bile ducts than in those with non-dilated bile ducts, when biliary puncture under US guidance was performed initially. However, even in patients with non-dilated bile ducts undergoing initial trials of biliary puncture under US guidance, the fluoroscopy time and the reported radiation dose were low, based on current studies. No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures and benign and malignant biliary stenosis/obstruction. Thus, US-guided PTBD was found to be a safe and effective technique that significantly reduced fluoroscopy time and radiation doses.

Case Report: Novel Splicing Variant in SH2D1A in a Patient With X-Linked Lymphoproliferative Syndrome Type 1

X-linked lymphoproliferative disease type 1 (XLP1), an X-linked recessive genetic disorder, is associated with primary immunodeficiency. Patients with XLP1 are susceptible to Epstein-Barr virus (EBV) infection. SH2D1A gene is known as the causative gene. We found a novel hemizygous variant of SH2D1A, c.162_201+31delinsTACAAGGACATATACA, from a 5-year-old male patient who had been diagnosed with EBV infection and Hodgkin's lymphoma. In targeted next-generation sequencing (NGS), complex variants at exon 2 were not consistently identified with two software programs. They showed a soft-clipped read pattern. The variant had a 71-bp deletion and a 16-bp insertion across exon 2 as confirmed by direct sequencing. As the variant was located within the exon-intron boundary, two aberrant transcripts were shown by RNA study. Although NGS method has a limitation in detecting large deletion/duplication variants, proper bioinformatics pipeline and careful review of data might enable the detection of complex variants.

Quantitative Analysis of Pancreatic Fat in Children with Obesity Using Magnetic Resonance Imaging and Ultrasonography

PURPOSE

The aim of this study was to evaluate the pancreatic fat fraction (PFF) using magnetic resonance imaging (MRI) in children with and without obesity and to correlate PFF with body mass index (BMI) z-score, hepatic fat fraction (HFF), and ultrasonography-derived pancreato-perihepatic fat index (PPHFI).

METHODS

This prospective study included 45 children with obesity and 19 without obesity (control group). PFF and HFF were quantitatively assessed using the abdominal multi-echo Dixon method for MRI. The PPHFI was assessed using transabdominal ultrasonography. Anthropometric, MRI, and ultrasonographic characteristics were compared between the two groups. Correlations between PFF, HFF, PPHFI, and BMI z-scores in each group were also analyzed.

RESULTS

The PFF, HFF, PPHFI, and BMI z-score were higher in the group with obesity than in the control group (PFF: 6.65±3.42 vs. 1.78±0.55, HFF: 19.5±13.0 vs. 2.31±1, PPHFI: 3.65 ±1.63 vs. 0.94±0.31, BMI z-score: 2.27±0.56 vs. 0.42±0.54, p<0.01, respectively). PFF was correlated with BMI z-scores, PPHFI, and HFF in the obesity group, and multivariate analysis showed that PFF was strongly correlated with BMI z-score and PPHFI (p<0.05). The BMI z-score was strongly correlated with PFF in the control group (p<0.01).

CONCLUSION

These results suggest that MRI-derived PFF measures are associated with childhood obesity. PFF and PPHFI were also highly correlated in the obesity group. Therefore, PFF may be an objective index of pancreatic fat content and has the potential for clinical utility as a non-invasive biomarker for the assessment of childhood obesity.

Differential characteristics associated with progression of mitral and aortic regurgitation in patients undergoing kidney transplantation

Background

Heart valve regurgitation is common in patients with end-stage renal disease (ESRD). However, there are no data on the fate of mitral regurgitation (MR) and aortic regurgitation (AR) after kidney transplantation (KT). In this study, we sought to investigate regression or progression rates of MR and AR after KT in patients with ESRD. Moreover, we aimed to explore clinical and echocardiographic factors associated with the progression of MR and AR in patients undergoing KT.

Methods

Among 1,734 patients who underwent KT from 2005 to 2018 at a single tertiary hospital, 674 patients (407 men; mean 48±12 years) who underwent both pre- and post-KT echocardiography were analyzed comprehensively. Pre-KT echocardiography was performed within three months of KT, and post-KT echocardiography was done between 6 months and 24 months after KT. Severities of MR and AR were graded as no/trivial, mild, moderate, and severe according to the current guidelines. Regression was defined if the severity decreased by one or more grades, while progression was defined if the severity increased by one or more grades.

Results

Figure 1 shows the regression or progression of MR and AR after KT. 78 (11%) patients showed MR regression, but 41 (6%) experienced MR progression. 13 (2%) revealed AR regression, while 23 (4%) presented AR progression. In patients with MR progression, there were more cases of receiving a second KT, having mitral annular calcification, and showing lesser reduction of left atrial volume after KT. Patients with AR progression showed a longer hemodialysis duration, persistent hypertension after KT, and aortic root dilatation. Factors related to the progression of MR and AR showed statistically meaningful predictive values in a stepwise manner (Figure 2)

Conclusions

In patients undergoing KT, MR and AR may progress in patients with certain distinct characteristics. Different clinical and echocardiographic characteristics before KT, and reduction of hemodynamic loads after KT determine the progression of MR and AR. Further echocardiographic surveillances after KT are needed in patients with clinical and echocardiographic factors for progression of valve regurgitation.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and Clinical Features of Myocarditis/Pericarditis before the Introduction of mRNA COVID-19 Vaccine in Korean Children: a Multicenter Study

BACKGROUND

Korean health authority plans to vaccinate adolescents against coronavirus disease 2019 (COVID-19) starting high school seniors during the summer vacation of 2021. However, the myocarditis/pericarditis following COVID-19 vaccine has been reported recently in adolescents and young adults. This study was performed to answer the urgent questions about the basic epidemiology and clinical course of myocarditis/pericarditis in hospitalized patients prior to the introduction of COVID-19 vaccines in pediatric population.

METHODS

A retrospective medical record analysis including frequency, clinical characteristics, etiology and outcome of myocarditis/pericarditis was conducted in 17 years and younger patients who were hospitalized in two referral hospitals in Korea between 2010 and 2019.

RESULTS

Total 142 patients with myocarditis (n = 119) and/or pericarditis (n = 23) were identified. Median age was 5.4 years (interquartile range, 0.6-12.9 years; range, 11 days-17.8 years), and male was 61%. In adolescents aged 12-17 years, the male to female ratio was 3.2. Myocarditis/pericarditis occurred 0.70 per 1,000 in-patients during the study period: 0.96 (< 1 year), 0.50 (1-5 years), 0.67 (6-11 years) and 1.22 (12-17 years) per 1,000 in-patients, respectively. There was an increasing tendency for the annual frequency from 0.34 in 2010 to 1.25 per 1,000 in-patients in 2019 (P = 0.021). Among the 56 (40%) proven pathogens at admission, Mycoplasma pneumoniae (n = 11, 8%) and enterovirus (n = 10, 7%) were most common. Of the 142 patients, 99 (70%) required pediatric intensive care unit care and 10 (7%) received heart transplantation. In addition, 61 patients (61/131, 47%) without heart medication at admission needed heart medication when they were discharged. Eleven (7.7%) patients died, of which five patients were previously healthy. The median age of deceased patients was lower than the survival group (0.8 vs. 6.3 years, P = 0.014).

CONCLUSION

The frequency of myocarditis/pericarditis was highest among male adolescent in-patients; however, the outcome was favorable in this group without any mortality.

[Multicentric Florid Cystic Endosalpingiosis in Different Anatomical Spaces: A Case Report]

Endosalpingiosis is a condition that causes the non-neoplastic proliferation of ectopic tubal epithelium. Florid cystic endosalpingiosis is an atypical subtype that is very rarely reported. It presents as a mass-like feature and therefore needs to be differentiated from tumorous conditions. Here, we report the imaging findings of a case of multicentric florid cystic endosalpingiosis in the extraperitoneal pelvic cavity and the retroperitoneal spaces.

The Role of Interventional Radiology in Treatment of Patients with Acute Trauma: A Pictorial Essay

Acute trauma is a common cause of mortality in individuals aged < 40 years. As organ preservation has become important in treating trauma patients, the treatment is shifting from surgical management to non-operative management. A multidisciplinary team approach, including interventional radiology (IR), is essential for the optimal management of trauma patients, as IR plays an important role in injury evaluation and management. IR also contributes significantly to achieving the best clinical outcomes in critically ill trauma patients. This pictorial essay aims to present and summarize various interventional treatments in trauma patients requiring critical care.

Myositis as an Initial Presentation of Ulcerative Colitis before Gastrointestinal Symptoms

The musculoskeletal system can be involved as an extra-intestinal manifestation of inflammatory bowel disease. Among these, myositis in ulcerative colitis (UC) is very rare. A 14-year-old girl was admitted due to severe shoulder tenderness. She had complained of left jaw pain and swelling for the past 10 days. Inflammatory markers were elevated with no evidence of infectious etiology. Myositis was suspected by shoulder magnetic resonance imaging. Three days after admission, she developed hematochezia. Muscle biopsy and colonoscopy was performed due to worsening left mandibular area pain and persistent hematochezia. Colonoscopy showed consistent findings with UC. She was finally diagnosed with UC with myositis as an extra-intestinal manifestation. She showed a dramatic response to UC treatment. Gastrointestinal symptoms were well-controlled. After 14 months, UC symptoms and muscle pain were aggravated, which were relieved after steroid and cyclosporin treatment. We report a unique case of UC initially presented with myositis, preceding gastrointestinal symptoms.

Peru-15 (Choleragarde(®)), a live attenuated oral cholera vaccine, is safe and immunogenic in human immunodeficiency virus (HIV)-seropositive adults in Thailand

BACKGROUND

Many areas with endemic and epidemic cholera report significant levels of HIV transmission. According to the World Health Organization (WHO), over 95% of reported cholera cases occur in Africa, which also accounts for nearly 70% of people living with HIV/AIDS globally. Peru-15, a promising single dose live attenuated oral cholera vaccine (LA-OCV), was previously found to be safe and immunogenic in cholera endemic areas. However, no data on the vaccine's safety among HIV-seropositive adults had been collected.

METHODS

This study was a double-blinded, individually randomized, placebo-controlled trial enrolling HIV-seropositive adults, 18-45 years of age, conducted in Bangkok, Thailand, to assess the safety of Peru-15 in a HIV-seropositive cohort.

RESULTS

32 HIV infected subjects were randomized to receive either a single oral dose of the Peru-15 vaccine with a buffer or a placebo (buffer only). No serious adverse events were reported during the follow-up period in either group. The geometric mean fold (GMF) rise in V. cholerae O1 El Tor specific antibody titers between baseline and 7 days after dosing was 32.0 (p<0.001) in the vaccine group compared to 1.6 (p<0.14) in the placebo group. Among the 16 vaccinees,14 vaccinees (87.5%) had seroconversion compared to 1 of 16 placebo recipients (6.3%). V. cholerae was isolated from the stool of one vaccinee, and found to be genetically identical to the Peru-15 vaccine strain. There were no significant changes in HIV viral load or CD4 T-cell counts between vaccine and placebo groups.

CONCLUSION

Peru-15 was shown to be safe and immunogenic in HIV-seropositive Thai adults.

Olfaction after Endoscopic Sinus Surgery of Chronic Rhinosinusitis

Objectives:

Chronic rhinosinusitis (CRS) is one of the most common causes of olfactory dysfunction. After endoscopic sinus surgery (ESS), olfactory function may improve in most cases, but may not in others. The purpose of this study was to investigate the prognostic factors for olfaction improvement after endoscopic sinus surgery in CRS.

Methods:

A total of 103 patients (175 nostrils) with CRS who underwent ESS were studied. We performed olfactory function test for all patients using the butanol threshold test (BTT) and Cross Cultural Smell Identification test (CC-SIT) preoperatively and postoperatively. The patients’ subjective symptoms were also recorded using the visual analog scale (VAS) pre- and postoperatively. We also analyzed the duration of disease and preoperative computed tomography by Lund-Mackay score.

Results:

The improvement of olfactory function after ESS in patients with longer duration of symptoms was not significantly lower than in patients with shorter duration. In multivariable study, anosmics had better improvement than hyposmics in recovery of olfaction. There were significant differences in anterior ethmoid involvement between responder and non-responder group.

Conclusions:

The improvement of olfaction after ESS mainly depends on the degree of preoperative olfactory function and involvement of anterior ethmoid involvement. Therefore, for the better outcome of ESS especially in olfactory function, early and proper treatment (including ESS) for CRS will be necessary.

Upregulation and function of GADD45gamma in unilateral ureteral obstruction

We performed differential display analysis to determine transcriptional activity in the rat kidney, following unilateral ureteral obstruction and found a 12-fold increase in the expression of Growth Arrest and DNA Damage-45gamma (GADD45gamma), a stress-responsive molecule that interacts with cell-cycle proteins. GADD45gamma was strongly expressed in as little as 6 h following ureteric obstruction in the renal tubules, and was also found in kidney tissue of patients with chronic glomerulonephritis. Adenovirus-mediated expression of GADD45gamma in cultured renal tubular cells activated p38 along with a significant upregulation of C-C and C-X3-C chemokine ligands and fibrosis-related factors such as several matrix metalloproteinases, transforming growth factor-beta1, decorin, and bone morphogenetic protein 2. Silencing of GADD45gamma expression significantly blunted the upregulation of these inflammatory and fibrogenic mediators and monocyte infiltration in the ureteral obstructed rat kidney. Our study shows that GADD45gamma is quickly upregulated in the kidney with an obstructed ureter, enhancing the production of factors regulating the pathogenesis of kidney disease.

The burden of cholera in the slums of Kolkata, India: data from a prospective, community based study

AIMS

To conduct a prospective, community based study in an impoverished urban site in Kolkata (formerly Calcutta) in order to measure the burden of cholera, describe its epidemiology, and search for potential risk factors that could be addressed by public health strategies.

METHODS

The study population was enumerated at the beginning and end of the study period. Surveillance through five field outposts and two referral hospitals for acute, watery, non-bloody diarrhoea was conducted from 1 May 2003 to 30 April 2004. Data and a stool sample for culture of Vibrio cholerae were collected from each patient. Treatment was provided in accordance with national guidelines.

RESULTS

From 62 329 individuals under surveillance, 3284 diarrhoea episodes were detected, of which 3276 (99%) had a stool sample collected and 126 (4%) were culture confirmed cholera. Nineteen (15%) were children less than 2 years of age, 29 (23%) had severe dehydration, and 48 (38%) were hospitalised. Risk factors for cholera included a household member with cholera during the period of surveillance, young age, and lower educational level.

CONCLUSIONS

There was a substantial burden of cholera in Kolkata with risk factors not easily amenable to intervention. Young children bear the brunt not only of diarrhoeal diseases in general, but of cholera as well. Mass vaccination could be a potentially useful tool to prevent and control seasonal cholera in this community.

Fermented mushroom milk-supplemented dietary fibre prevents the onset of obesity and hypertriglyceridaemia in Otsuka Long-Evans Tokushima fatty rats

AIM

Fermented milk product containing edible mushroom water extracts (mushroom yogurt; MY) has been reported to have glycaemic control and triglyceride-lowering effects in streptozotocin (STZ)-induced diabetic rats and Zucker diabetic fatty (ZDF) rats. Here, we investigated how MY-supplemented dietary fibre (10 and 20%, v/w) influences the onset of obesity and hypertriglyceridaemia in Otsuka Long-Evans Tokushima fatty (OLETF) rats.

METHODS

The OLETF rats were fed a powdered chow diet supplemented with MY at the levels of 10 (v/w) and 20% for 6 weeks from 10 weeks of age, but the OLETF control rats were not supplemented. Their weight, fat distribution and lipid profile have been determined.

RESULTS

The body weights in MY-fed rats were reduced compared with the control rats. The perirenal fat was decreased in both MY groups, but the visceral and epididymal fats reduced only in the MY 20% group. The concentrations of serum triglyceride and non-esterified fatty acid in MY-fed rats were decreased in a dose-dependent manner. However, the levels of other serum lipid profiles [total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol] were comparable among all rats.

CONCLUSION

Anti-obesity and triglyceride lowering by MY-supplemented dietary fibre in OLETF rats might have resulted from the synergistic effect of components in the fermented mushroom-milk product.

Incidence of Haemophilus influenzae type b and other invasive diseases in South Korean children

To determine incidence of invasive Haemophilus influenzae type b (Hib) disease in a defined population of Jeonbuk Province, Korea, children <5 years were evaluated in prospective, population-based surveillance of invasive bacterial diseases using standardized methods for patient referral, clinical evaluation and laboratory testing (optimized culture, latex agglutination, polymerase chain reaction). Vaccine utilization was assessed with vaccination histories of patients in surveillance, monthly data on Hib vaccine distribution and a coverage survey of clinic patients in study population. From September 1999 to December 2001, 2176 children were evaluated for possible meningitis, 1541 had no cerebrospinal fluid (CSF) findings of meningitis, 605 had CSF abnormalities (suspected bacterial meningitis) but no pathogen identified; six patients had probable Hib meningitis and eight had confirmed Hib meningitis. The annual suspected bacterial meningitis incidence was 258.4/100,000 <5 years and the probable/confirmed Hib meningitis incidence was 6.0/100,000 <5 years. Pneumococcal meningitis incidence was 2.1/100,000 <5 years and Group B streptococcal meningitis incidence was 0.17/1000 live births. A total of 69,589 Hib vaccine doses were distributed during the study. Hib vaccine coverage was negligible initially but increased to 16% (complete Hib immunization) and 27% (partial immunization) in final months of study. Suspected bacterial meningitis incidence was high but proven invasive Hib meningitis incidence was low. Hib was leading cause of bacterial meningitis yet bacterial pathogens were identified in only 4% of abnormal CSF. These findings may reflect truly low incidence, presumptive antibiotic treatment, partial Hib immunization, or incomplete clinical evaluations. Given the apparent Hib meningitis burden in Jeonbuk Province, additional studies to describe other invasive Hib syndromes, Hib-associated mortality and disability, and economic impact of Hib disease will be useful to guide public health decisions regarding routine Hib vaccine introduction.

Pressure activation of the chaperone function of small heat shock proteins

Small heat shock proteins play an important role in the stress response of cells and in several other cellular functions. They possess chaperone-like activity; i.e. they can bind and protect damaged proteins from aggregation and maintain them in a folding-competent state. Two members of this family were investigated in this work: bovine alpha-crystallin and heat shock protein (HSP)16.5 from the thermophilic archaebacteria Methanococcus jannaschii. We reported earlier the enhancement of chaperone potency of alpha-crystallin by high pressure. We now report the completion of the work with results on HSP16.5. The chaperone potency of both proteins can be enhanced significantly by applying high pressure. Evidence by light scattering, Fourier transform infrared (FT-IR) and tryptophan fluorescence experiments show that while the secondary and tertiary structure of these proteins are not influenced by high pressure, their quatemary structure becomes affected: H bonds between subunits are weakened or broken, tryptophan environments become more polar, oligomers dissociate to some extent. We conclude that the oligomeric structure of both proteins is loosened, resulting in stronger dynamics and in more accessible hydrophobic surfaces. These properties lead to increased chaperone potency.

Premenstrual dysphoric disorder and psychiatric co-morbidity

Premenstrual dysphoric disorder (PMDD) can occur co-morbidly with other axis I disorders, particularly mood and anxiety disorders. The data supporting this diagnostic dilemma are reviewed in terms of methodological comparisons between studies. The point prevalence of the co-occurrence of PMDD and other psychiatric disorders is discussed as well as implications for treatment and further study.

Factor analysis of the metabolic syndrome among elderly Koreans--the South-west Seoul Study

AIMS

To examine the relationship between the components of the metabolic syndrome and to explore whether insulin resistance unifies the clustering of components of the metabolic syndrome among urban elderly Koreans using exploratory factor analysis.

METHODS

We included 1314 non-diabetic subjects over the age of 60 years, selected from a cross-sectional study, which was conducted in 1999 in Seoul, Korea. Factor analysis was carried out using the principle components analysis with Varimax orthogonal rotation of the components of the metabolic syndrome.

RESULTS

We found four major factors of cardiovascular disease risk variables in our study subjects. Impaired glucose tolerance, dyslipidaemia, hypertension and obesity aggregated as the major domain. Obesity and dyslipidaemia variables were closely related and loaded on the same factor. However, hypertension was not linked closely with other factors of the metabolic syndrome.

CONCLUSIONS

Insulin resistance is not the only contributor to the metabolic syndrome among urban elderly Koreans. Although the components of the metabolic syndrome were closely related, the finding of more than one factor suggests that more than one pathophysiological mechanism underlies full expression of the metabolic syndrome among elderly Koreans.

Comparison of ADA and WHO criteria for the diagnosis of diabetes in elderly Koreans

AIMS

This study was conducted to compare the prevalence and cardiovascular risk factors of different categories of glucose tolerance in the elderly Korean population using World Health Organization (WHO) and American Diabetes Association (ADA) criteria.

METHODS

This study included 1456 non-diabetic subjects over the age of 60 years, selected from a cross-sectional study, which was conducted in 1999 in Seoul, Korea. Fasting and post-challenge 2-h plasma glucose, insulin levels, body mass index (BMI), waist-hip ratio (WHR), blood pressure, and lipid profiles were examined. Prevalence of glucose tolerance categories and the level of agreement (kappa statistics) were obtained using WHO 2-h criteria and ADA fasting criteria. Comparison of cardiovascular risk factors among several concordant and discordant glucose intolerance groups was done.

RESULTS

The prevalence rates of newly diagnosed diabetes of elderly men defined by WHO 2-h criteria and ADA fasting criteria were 11.8% and 4.8%, respectively. That of elderly women was 8.1% by WHO 2-h criteria and 3.1% by ADA fasting criteria. The prevalence of impaired glucose tolerance (IGT) by WHO criteria was also higher than that of impaired fasting glucose (IFG) by ADA criteria (23.5% vs. 10.0% men, 23.7% vs. 7.5% women). The level of agreement between ADA fasting criteria and WHO 2-h criteria was low (weighted kappa = 0.228 men, weighted kappa = 0.301 women). The concordant diabetic women by both ADA fasting criteria and WHO 2-h criteria showed higher BMI, WHR, diastolic blood pressure, total cholesterol and triglyceride levels than concordant normal subjects. However, the isolated post-challenge hyperglycaemia (IPH) women group was not different significantly from the concordant normal women group except in BMI.

CONCLUSIONS

Our results clearly show that the 1997 ADA fasting criteria are less sensitive for diagnosing diabetes than oral glucose tolerance test (OGTT)-based WHO criteria in elderly Koreans. Also, there is a poor agreement of different categories of glucose tolerance between ADA and WHO criteria; therefore, the OGTT remains a valuable test in diagnosing diabetes and classifying various categories of glucose intolerance, especially in elderly Koreans.

Cloning and expression of novel mosaic serine proteases with and without a transmembrane domain from human lung

Two cDNAs encoding novel mosaic proteins with a serine protease domain and potential regulatory modules, consisting of a protein kinase substrate and a low-density lipoprotein receptor, were cloned from a human lung cDNA library by PCR. One with a transmembrane domain (MSPL) and the other without one (MSPS) comprise 581 and 537 amino acids, respectively. Except for the C-terminal ends, the two isoforms had an identical serine protease domain exhibiting 42, 39 and 43% identity with those of plasma kallikrein, hepsin and transmembrane protease serine 2, respectively. Both genes were predominantly expressed in human lung, placenta, pancreas and prostate.

V(D)J recombination: site-specific cleavage and repair

V(D)J recombination is a site-specific gene rearrangement process that contributes to the diversity of antigen receptor repertoires. Two lymphoid-specific proteins, RAG1 and RAG2, initiate this process at two recombination signal sequences. Due to the recent development of an in vitro assay for V(D)J cleavage, the mechanism of cleavage has been elucidated clearly. The RAG complex recognizes a recombination signal sequence, makes a nick at the border between signal and coding sequence, and carries out a transesterification reaction, resulting in the production of a hairpin structure at the coding sequence and DNA double-strand breaks at the signal ends. RAG1 possesses the active site of the V(D)J recombinase although RAG2 is essential for signal binding and cleavage. After DNA cleavage by the RAG complex, the broken DNA ends are rejoined by the coordinated action of DNA double-strand break repair proteins as well as the RAG complex. The junctional variability resulting from imprecise joining of the coding sequences contributes additional diversity to the antigen receptors.

Mutations of acidic residues in RAG1 define the active site of the V(D)J recombinase

The RAG1 and RAG2 proteins collaborate to initiate V(D)J recombination by binding recombination signal sequences (RSSs) and making a double-strand break between the RSS and adjacent coding DNA. Like the reactions of their biochemical cousins, the bacterial transposases and retroviral integrases, cleavage by the RAG proteins requires a divalent metal ion but does not involve a covalent protein/DNA intermediate. In the transposase/integrase family, a triplet of acidic residues, commonly called a DDE motif, is often found to coordinate the metal ion used for catalysis. We show here that mutations in each of three acidic residues in RAG1 result in mutant derivatives that can bind the RSS but whose ability to catalyze either of the two chemical steps of V(D)J cleavage (nicking and hairpin formation) is severely impaired. Because both chemical steps are affected by the same mutations, a single active site appears responsible for both reactions. Two independent lines of evidence demonstrate that at least two of these acidic residues are directly involved in coordinating a divalent metal ion: The substitution of Cys for Asp allows rescue of some catalytic function, whereas an alanine substitution is no longer subject to iron-induced hydroxyl radical cleavage. Our results support a model in which the RAG1 protein contains the active site of the V(D)J recombinase and are interpreted in light of predictions about the structure of RAG1.

Functional analysis of coordinated cleavage in V(D)J recombination

V(D)J recombination in vivo requires a pair of signals with distinct spacer elements of 12 and 23 bp that separate conserved heptamer and nonamer motifs. Cleavage in vitro by the RAG1 and RAG2 proteins can occur at individual signals when the reaction buffer contains Mn2+, but cleavage is restricted to substrates containing two signals when Mg2+ is the divalent cation. By using a novel V(D)J cleavage substrate, we show that while the RAG proteins alone establish a moderate preference for a 12/23 pair versus a 12/12 pair, a much stricter dependence of cleavage on the 12/23 signal pair is produced by the inclusion of HMG1 and competitor double-stranded DNA. The competitor DNA serves to inhibit the cleavage of substrates carrying a 12/12 or 23/23 pair, as well as the cutting at individual signals in 12/23 substrates. We show that a 23/33 pair is more efficiently recombined than a 12/33 pair, suggesting that the 12/23 rule can be generalized to a requirement for spacers that differ from each other by a single helical turn. Furthermore, we suggest that a fixed spatial orientation of signals is required for cleavage. In general, the same signal variants that can be cleaved singly can function under conditions in which a signal pair is required. However, a chemically modified substrate with one noncleavable signal enables us to show that formation of a functional cleavage complex is mechanistically separable from the cleavage reaction itself and that although cleavage requires a pair of signals, cutting does not have to occur simultaneously at both. The implications of these results are discussed with respect to the mechanism of V(D)J recombination and the generation of chromosomal translocations.

Amino acid sequence of piguamerin, an antistasin-type protease inhibitor from the blood sucking leech Hirudo nipponia

A serine-protease inhibitor of plasma kallikrein was screened and purified from a native Korean leech species, Hirudo nipponia. The peptide, named piguamerin, potently inhibited plasma and tissue kallikreins, and trypsin. Sequence analyses by automated Edman degradation revealed 48 amino acid residues and a molecular mass for the peptide of 5090 Da. Piguamerin is similar to antistasin-type inhibitors with the same spacing of ten cysteine residues, but shows differences from hirustasin, antistasin and ghilanten at the residues surrounding Arg27, which is a common P1 reactive residue for these inhibitors. The purified inhibitor modulated plasma clotting in tests of activated partial thromboplastin time at nanomolar concentrations. The serine-protease inhibitor of this leech may be involved in leech hematophagia.

Role of the core DNA polymerase III subunits at the replication fork. Alpha is the only subunit required for processive replication

The DNA polymerase III holoenzyme is composed of 10 subunits. The core of the polymerase contains the catalytic polymerase subunit, alpha, the proofreading 3'-->5' exonuclease, epsilon, and a subunit of unknown function, theta. The availability of the holoenzyme subunits in purified form has allowed us to investigate their roles at the replication fork. We show here that of the three subunits in the core polymerase, only alpha is required to form processive replication forks that move at high rates and that exhibit coupled leading- and lagging-strand synthesis in vitro. Taken together with previous data this suggests that the primary determinant of replication fork processivity is the interaction between another holoenzyme subunit, tau, and the replication fork helicase, DnaB.

Localization of the active site of the alpha subunit of the Escherichia coli DNA polymerase III holoenzyme

Using a deletion approach on the alpha subunit of DNA polymerase III from Escherichia coli, we show that there is an N-proximal polymerase domain which is distinct from a more C-proximal tau and beta binding domain. Although deletion of 60 residues from the alpha N terminus abolishes polymerase activity, deletions of 48, 169, and 342 amino acids from the C terminus progressively impair its catalytic efficiency but preserve an active site. Deletion of 342 C-terminal residues reduces k(cat) 46-fold, increases the Km for gapped DNA 5.5-fold, and increases the Km for deoxynucleoside triphosphates (dNTPs) twofold. The 818-residue protein with polymerase activity displays typical Michaelis-Menten behavior, catalyzing a polymerase reaction that is saturable with substrate and linear with time. With the aid of newly acquired sequences of the polymerase III alpha subunit from a variety of organisms, candidates for two key aspartate residues in the active site are identified at amino acids 401 and 403 of the E. coli sequence by inspection of conserved acidic amino acids. The motif Pro-Asp-X-Asp, where X is a hydrophobic amino acid, is shown to be conserved among all known DnaE proteins, including those from Bacillaceae, cyanobacteria, Mycoplasma, and mycobacteria. The E. coli DnaE deletion protein with only the N-terminal 366 amino acids does not have polymerase activity, consistent with the proposed position of the active-site residues.

Identification of the beta-binding domain of the alpha subunit of Escherichia coli polymerase III holoenzyme

Rapid and processive DNA synthesis by Escherichia coli DNA polymerase III holoenzyme is achieved by the direct interaction between the alpha subunit of DNA polymerase III core and the beta sliding clamp (LaDuca, R. J., Crute, J. J., McHenry, C. S., and Bambara, R. A. (1986) J. Biol. Chem. 261, 7550-7557; Stukenberg, T. P., Studwell-Vaughan, P. S., and O'Donnell, M. (1991) J. Biol. Chem. 266, 11328-11334). In this study, we localized the beta-binding domain of alpha to a carboxyl-terminal region by quantifying the interaction of beta with a series of alpha deletion proteins. Purification and binding analysis was facilitated by insertion of hexahistidine and short biotinylation sequences on the deletion terminus of alpha. Interaction of beta with alpha deletion proteins was studied by gel filtration and surface plasmon resonance. alpha lacking 169 COOH-terminal residues still possessed beta-binding activity; whereas deletion of 342 amino acids from the COOH terminus abolished beta binding. Deletion of 542 amino acids from the NH2 terminus of the 1160 residue alpha subunit resulted in a protein that bound beta 10-20-fold more strongly than native alpha. Hence, portions of alpha between residues 542 and 991 are involved in beta binding. DNA binding to alpha apparently triggers an increased affinity for beta (Naktinis, V., Turner, J., and O'Donnell, M. (1996) Cell 84, 137-145). Our findings extend this observation by implicating the amino-terminal polymerase domain in inducing a low affinity taut conformation in the carboxyl-terminal beta-binding domain. Deletion of the polymerase domain (or, presumably, its occupancy by DNA) relaxes the COOH-terminal domain, permitting it to assume a conformation with high affinity for beta.

In vivo assembly of overproduced DNA polymerase III. Overproduction, purification, and characterization of the alpha, alpha-epsilon, and alpha-epsilon-theta subunits

The genes for the polymerase core (alphaepsilontheta) of the DNA polymerase III holoenzyme map to widely separated loci on the Escherichia coli chromosome. To enable efficient overproduction and in vivo assembly of DNA polymerase III core, artificial operons containing the three structural genes, dnaE, dnaQ, and holE, were placed in an expression plasmid. The proteins alpha, alphaepsilon and alphaepsilontheta were overexpressed and assembled in E. coli and purified to homogeneity. The three purified polymerases had a similar specific activity of about 6.0 x 10(6) units/mg in a gap-filling assay. Kinetics studies showed that neither epsilon nor theta influenced the Km of alpha for deoxynucleotide triphosphate and only slightly decreased the Km of alpha for DNA, although epsilon was absolutely required for maximal DNA synthesis. The rate of DNA synthesis by alpha-reconstituted holoenzyme using tau complex was about 5-fold less than that of alphaepsilon or alphaepsilontheta-reconstituted holoenzyme as determined by a gel analysis. The processivity of alpha-reconstituted holoenzyme was very similar to that of alphaepsilontheta-reconstituted holoenzyme when tau complex was used as a clamp loader.

Biotin tagging deletion analysis of domain limits involved in protein-macromolecular interactions. Mapping the tau binding domain of the DNA polymerase III alpha subunit

The tau subunit dimerizes DNA polymerase III via interaction with the alpha subunit, allowing DNA polymerase III holoenzyme to synthesize both leading and lagging strands simultaneously at the DNA replication fork. Here, we report a general method to map the limits of domains required for heterologous protein-protein interactions using surface plasmon resonance. The method employs fusion of a short biotinylation sequence at either the NH2 or COOH terminus of the protein to be immobilized on streptavidin-derivatized biosensor chips. Inclusion of a hexahistidine sequence permits rapid purification and separation of the fusion protein from the endogenous Escherichia coli biotin carboxyl carrier protein. Ten deletions of the alpha subunit were constructed and purified by Ni2+-nitrilotriacetic acid chromatography and, when required, monomeric avidin chromatography. Each alpha deletion protein was captured by streptavidin immobilized on a Pharmacia Biosensor BIAcore chip, and the tau binding activity of each alpha deletion was analyzed using surface plasmon resonance. The tau subunit bound very tightly to a full-length amino-terminal fusion of the biotinylation sequence with alpha (KD approximately 70 pm). Four additional NH2-terminal alpha deletion proteins (60, 240, 360, and 542 residues deleted) retained strong binding activity to the tau subunit (KD = 0.19-0.39 nM), whereas deletion of 705 residues or more from the NH2 terminus of the alpha subunit abolished tau binding activity. Full-length alpha that contained a carboxyl-terminal fusion with the biotinylation sequence bound tau strongly (KD = 0.37 nM). However, deletion of 48 amino acids from the COOH terminus totally eliminated tau binding. These results indicate that the COOH-terminal half of the alpha subunit is involved in tau interaction.

A cysteine-rich serine protease inhibitor (Guamerin II) from the non-blood sucking leech Whitmania edentula: biochemical characterization and amino acid sequence analysis

A cysteine-rich serine protease inhibitor (Guamerin II) was isolated from the non-blood sucking leech Whitmania edentula. The new inhibitor was identified as a low molecular weight (6,012 Da) polypeptide with some sequence similarities to antistasin, hirustasin and guamerin. The inhibitor contained 56 amino acid residues with 76.8% sequence similarity to guamerin, 48.2% to hirustasin and 28.6% to the first domain of antistasin. This new inhibitor was the first completely sequenced serine protease inhibitor from a non-blood sucking leech. Analysis of the inhibitor revealed that it was active against neutrophil elastase and chymotrypsin, but had no activity against a variety of other proteases. The P1 reactive site residue was identified as methionine and the residues surrounding the P1 site were hydrophobic amino acids. The primary structure of the inhibitor showed no similarity to well-known elastase inhibitors from leeches such as eglin.

Isolation, sequencing and overexpression of the gene encoding the theta subunit of DNA polymerase III holoenzyme

The gene encoding the theta subunit of DNA polymerase III holoenzyme, designated holE, was isolated using a strategy in which peptide sequence was used to derive a DNA hybridization probe. Sequencing of the gene, which maps to 41.43 centisomes of the chromosome, revealed a 76-codon open reading frame predicted to produce a protein of 8,846 Da. When placed in a tac promoter expression vector, the open reading frame directed expression of a protein, that comigrated with authentic theta subunit from purified holoenzyme, to 6% of total soluble protein.