Lelliottia wanjuensis sp. nov. Isolated from Korean Lettuce in Wanju, South Korea.

Ten Gram stain-negative, oxidase-negative, catalase-positive, rod-shaped strains were isolated from lettuce in the city Wanju in South Korea. Comparative 16S rRNA gene analysis and multilocus sequence analysis indicated that the strains grouped closely together with all other Lelliottia (L.)-type strains. The average nucleotide identity (ANI) comparisons of the isolates showed a high relationship between the strains, as the ANI values of all strains ranged from 91.01 to 91.31% when compared to the L. jeotgali-type strain PFL01T. All isolates showed the highest genomic DNA sequence similarity to the L. jeotgali PFL01T strain at 43.3% when compared with digital DNA-DNA hybridization (dDDH). Strain V104_15T of the proposed novel Lelliottia species showed 91.2% and 43.3% similarity with the most closely related L. jeotgali PFL01T-type strain in the ANI and dDDH comparisons, respectively. Strain V104_15T could not grow at 45 °C and 7% NaCl, while L. jeotgali PFL01T strain could grow at both these conditions. Strain V104_15T showed ß-glucosidase activity but not α-glucosidase activity, while the L. jeotgali PFL01T strain was α-glucosidase positive but ß-glucosidase negative. The major cellular fatty acids of strain V104_15T were C16:0 and cyclo-C17:0 including summed features. The mol % G + C content of the genomic DNA of strain V104_15T was 55.74%. Phenotypic and biochemical characteristics, as well as the phylogenomic analysis indicated that the strain V104_15T represents a novel species of the genus Lelliottia, for which the name Lelliottia wanjuensis sp. nov. is proposed. The type strain is V104_15T (= LMG 32996 T = DSM 115585 T).

Orphan Nuclear Receptor ERRγ Is a Transcriptional Regulator of CB1 Receptor-Mediated TFR2 Gene Expression in Hepatocytes.

Orphan nuclear receptor estrogen-related receptor γ (ERRγ) is an important transcription factor modulating gene transcription involved in endocrine control of liver metabolism. Transferrin receptor 2 (TFR2), a carrier protein for transferrin, is involved in hepatic iron overload in alcoholic liver disease (ALD). However, TFR2 gene transcriptional regulation in hepatocytes remains largely unknown. In this study, we described a detailed molecular mechanism of hepatic TFR2 gene expression involving ERRγ in response to an endocannabinoid 2-arachidonoylglycerol (2-AG). Treatment with 2-AG and arachidonyl-2'-chloroethylamide, a selective cannabinoid receptor type 1 (CB1) receptor agonist, increased ERRγ and TFR2 expression in hepatocytes. Overexpression of ERRγ was sufficient to induce TFR2 expression in both human and mouse hepatocytes. In addition, ERRγ knockdown significantly decreased 2-AG or alcohol-mediated TFR2 gene expression in cultured hepatocytes and mouse livers. Finally, deletion and mutation analysis of the TFR2 gene promoter demonstrated that ERRγ directly modulated TFR2 gene transcription via binding to an ERR-response element. This was further confirmed by chromatin immunoprecipitation assay. Taken together, these results reveal a previously unrecognized role of ERRγ in the transcriptional regulation of TFR2 gene expression in response to alcohol.

Multimodal intraoperative monitoring during intramedullary spinal cord tumor surgery.

BACKGROUND: The aim of this work is to evaluate the utility of multimodal intraoperative monitoring (IOM) during intramedullary spinal cord tumor (IMSCT) surgery in our institution, and to investigate which IOM events are likely to be encountered during critical surgical phases. METHODS: Twenty-five patients who underwent IMSCT surgery with IOM were included in this study. Our multimodal IOM assessment included SSEP, mMEP, and fEMG monitoring. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity were assessed 24 h and 1 month after surgery. The IOM events during three main surgical phases were also investigated. For mMEP assessment, two warning criteria (>50 % decrease in mMEP amplitude and all-or-none mMEP amplitude presence) were employed. RESULTS: Long-term outcome prediction was better when the all-or-none criterion was applied than when the >50 % amplitude decrease criterion was applied. Based on the all-or-none criterion, the PPV, NPV, sensitivity, and specificity were 60, 100, 100, and 91 %. Frequent IOM events were observed during the three major main surgical phases. Seven (29 %) patients showed SSEP events during opening of the spinal cord. During tumor removal, 21 of 25 patients (84 %) had IOM events, and 13 of 18 (72 %) of the fEMG events occurred prior to the mMEP events. CONCLUSIONS: Based on the association of fEMG events with upcoming mMEP events during tumor removal, we recommend inclusion of fEMG monitoring in IOM. Multimodal IOM provides useful electrophysiological information during IMSCT surgery, especially during the main surgical phases.

Clinical features and treatment outcomes of Langerhans cell histiocytosis: a nationwide survey from Korea histiocytosis working party.

A nationwide survey was conducted to clarify the clinical features and outcomes of Korean children with Langerhans cell histiocytosis (LCH). Korea Histiocytosis Working Party analyzed the data of 603 patients who were diagnosed with LCH between 1986 and 2010 from 28 institutions in Korea. Median age at diagnosis was 65 months (range, 0 to 276 mo). Bone was the most frequently affected organ (79.6%) followed by skin (19.2%). Initially, 419 patients (69.5%) had single-system involvement (SS), 85 (14.1%) with multisystem (MS) disease without risk organ involvement (MS-RO), and 99 (16.4%) multisystem disease with risk organ involvement (MS-RO). The 5-year overall survival (OS) rates in the SS, MS-RO, and MS-RO groups were 99.8%, 98.4%, and 77.0%, respectively (P<0.001), and the 5-year reactivation rates were 17.9%, 33.5%, and 34.3%, respectively (P<0.001). The OS rate was lower in patients with RO involvement (P=0.025) and lack of response to initial treatment (P=0.001). MS involvement (P=0.036) was an independent risk factor for reactivation. Permanent consequences were documented in 99 patients (16.4%). Reactivation of disease, MS involvement, and age at diagnosis ≤ 2 years were associated with higher incidence of permanent consequences. This study emphasized that further efforts are required to improve survival of MS-RO patients and reduce reactivation in younger patients with MS involvement.

Novel Qnr Families as Conserved and Intrinsic Quinolone Resistance Determinants in Aeromonas spp.

The environment has been identified as an origin, reservoir, and transmission route of antibiotic resistance genes (ARGs). Among diverse environments, freshwater environments have been recognized as pivotal in the transmission of ARGs between opportunistic pathogens and autochthonous bacteria such as Aeromonas spp. In this study, five environmental strains of Aeromonas spp. exhibiting multidrug resistance (MDR) were selected for whole-genome sequencing to ascertain their taxonomic assignment at the species-level and to delineate their ARG repertoires. Analyses of their genomes revealed the presence of one protein almost identical to AhQnr (A. hydrophila Qnr protein) and four novel proteins similar to AhQnr. To scrutinize the classification and taxonomic distribution of these proteins, all Aeromonas genomes deposited in the NCBI RefSeq genome database (1,222 genomes) were investigated. This revealed that these Aeromonas Qnr (AQnr) proteins are conserved intrinsic resistance determinants of the genus, exhibiting species-specific diversity. Additionally, structure prediction and analysis of contribution to quinolone resistance by AQnr proteins of the isolates, confirmed their functionality as quinolone resistance determinants. Given the origin of mobile qnr genes from aquatic bacteria and the crucial role of Aeromonas spp. in ARG dissemination in aquatic environments, a thorough understanding and strict surveillance of AQnr families prior to the clinical emergence are imperative. In this study, using comparative genome analyses and functional characterization of AQnr proteins in the genus Aeromonas, novel Aeromonas ARGs requiring surveillance has suggested.

Founder effects in two predominant intronic mutations of UNC13D, c.118-308C>T and c.754-1G>C underlie the unusual predominance of type 3 familial hemophagocytic lymphohistiocytosis (FHL3) in Korea.

Familial hemophagocytic lymphohistiocytosis (familial HLH or FHL) is a potentially fatal autosomal recessive disorder. Our previous study demonstrated that UNC13D mutations (FHL3) account for ~90 % of FHL in Korea with recurrent splicing mutation c.754-1G>C (IVS9-1G>C). Notably, half of the FHL3 patients had a monoallelic mutation of UNC13D. Deep intronic mutations in UNC13D were recently reported in patients of European descent. In this study, we performed targeted mutation analyses for deep intronic mutations and investigated on the founder effect in FHL3 in Korean patients. The study patients were 72 children with HLH including those with FHL3 previously reported to have a monoallelic UNC13D mutation. All patients were recruited from the Korean Registry of Hemophagocytic Lymphohistiocytosis. In addition to conventional sequencing of FHL2-4, targeted tests for c.118-308C>T and large intronic rearrangement mutations of UNC13D were performed. Haplotype analysis was performed for founder effects using polymorphic markers in the FHL3 locus. FHL mutations were detected in 20 patients (28 %). Seventeen patients had UNC13D mutations (FHL3, 85 %) and three had PRF1 mutations (FHL2, 15 %). UNC13D:c.118-308C>T was detected in ten patients, accounting for 38 % of all mutant alleles of UNC13D, followed by c.754-1G>C (26 %). Haplotype analyses revealed significantly shared haplotypes in both c.118-308C>T and c.754-1G>C, indicating the presence of founder effects. The deep intronic mutation UNC13D:c.118-308C>T accounts for the majority of previously missing mutations and is the most frequent mutation in FHL3 in Korea. Founder effects of two recurrent intronic mutations of UNC13D explain the unusual predominance of FHL3 in Korea.

Nutrition Intervention in a Gastric Cancer Patient With Gastrectomy for 12 Months: A Case Report.

Gastrectomy is the most effective method of treating gastric cancer, but it is commonly associated with weight loss, nutritional deficiencies, and the increased risk of malnutrition due to post-surgery complications, including gastric stasis, dumping syndrome, malabsorption, and maldigestion. Malnutrition is a risk factor for postoperative complications and poor prognosis. To prevent it and guarantee a quick recovery after surgery, continuous and individualized nutrition intervention should be performed both before surgery and postoperatively. The Department of Dietetics at Samsung Medical Center (SMC) performed nutritional status assessment before gastrectomy, initial nutritional assessment within 24 hours of admission, description of therapeutic diet after surgery, nutrition counselling before discharge, and nutritional status assessment and individual nutrition counselling after 1, 3, 6, and 12 months from surgery. This is a case report of a patient who underwent gastrectomy as well as intensive nutrition intervention in SMC.

Characterization and genomic insight of surfactin-producing Bacillus velezensis and its biocontrol potential against pathogenic contamination in lettuce hydroponics.

Due to food borne pathogen, maintaining the viability of fresh fruits and vegetable is a great concern. Several strategies including microbial and plant-based formulations to reduce their infection and maintain quality of the fresh food are in practice. Currently, Bacillus has gained significant traction as a biocontrol agent for regulating diseases affecting a variety of agricultural and horticultural crops. Food-grade citric acid and plant growth-promoting rhizobacteria (PGPR) were used as antimicrobial agent, MIC results showed that PGPR (14.87 mm) and CA (20.25 mm) exhibited notable antimicrobial activity against E. coli. Lettuce treated with PGPR showed reduction in E. coli contamination, E. coli was detected at 3.30, 3.68 in control, and 2.7 log CFU/g in random root injury lettuce inoculated with PGPR KACC 21110 respectively. Random root injury showed a trend toward increasing E. coli internalization. The strains exhibited resistance to multiple antibiotics, including Imipenem, tetracycline, ampicillin, cefotaxime, cefoxitin, and ceftriaxone. Comprehensive data analysis revealed the presence of ten putative bacteriocin or bacteriocin-like gene clusters. The structure of lipopeptide homologs was characterized by using QTOF-MS/MS. The mass ion peaks attributed to surfactin homologs, surfactin A ion at m/z 1008.66, surfactin B, C at m/z 1022.67 and 1036.69. In addition to surfactin, a polyketide oxydifficidin and lipopeptide NO were extracted and detected from the extract of B. velezensis. Both isolates are key biocontrol agents and have significant potential in combating foodborne pathogens and can be utilized to explore novel antibacterial products for preventing pathogens in fresh produce.

Identification and Characterization of Antibiotic-Resistant, Gram-Negative Bacteria Isolated from Korean Fresh Produce and Agricultural Environment.

The consumption of fresh produce and fruits has increased over the last few years as a result of increasing consumer awareness of healthy lifestyles. Several studies have shown that fresh produces and fruits could be potential sources of human pathogens and antibiotic-resistant bacteria. In this study, 248 strains were isolated from lettuce and surrounding soil samples, and 202 single isolates selected by the random amplified polymorphic DNA (RAPD) fingerprinting method were further characterized. From 202 strains, 184 (91.2%) could be identified based on 16S rRNA gene sequencing, while 18 isolates (8.9%) could not be unequivocally identified. A total of 133 (69.3%) and 105 (54.7%) strains showed a resistance phenotype to ampicillin and cefoxitin, respectively, while resistance to gentamicin, tobramycin, ciprofloxacin, and tetracycline occurred only at low incidences. A closer investigation of selected strains by whole genome sequencing showed that seven of the fifteen sequenced strains did not possess any genes related to acquired antibiotic resistance. In addition, only one strain possessed potentially transferable antibiotic resistance genes together with plasmid-related sequences. Therefore, this study indicates that there is a low possibility of transferring antibiotic resistance by potential pathogenic enterobacteria via fresh produce in Korea. However, with regards to public health and consumer safety, fresh produce should nevertheless be continuously monitored to detect the occurrence of foodborne pathogens and to hinder the transfer of antibiotic resistance genes potentially present in these bacteria.

Different intraoperative decisions for undiagnosed paraganglioma: Two case reports.

BACKGROUND: Paragangliomas may be preoperatively misdiagnosed as non-functioning retroperitoneal tumors and are sometimes suspected only at the time of intraoperative manipulation. Without preoperative alpha blockade preparation, a hypertensive crisis during tumor manipulation and hypotension after tumor removal may result in critical consequences. Therefore, primary consideration should be given to the continuation or discontinuation of surgery on the basis of the possibility of gentle surgical manipulation and hemodynamic stabilization. We report two cases of paragangliomas detected intraoperatively. CASE SUMMARY: A 65-year-woman underwent laparoscopic small-bowel wedge resection. A hypertensive crisis occurred during manipulation of the mass, and an unrecognized catecholamine-producing paraganglioma was suspected. The surgeon and anesthesiologists believed that tumor excision could be performed with minimal manipulation of the tumor because the tumor was in a favorable location. Serious hemodynamic instability did not occur with aggressive use of vasoactive drugs. A week later, a 54-year-man underwent open resection of a 3-cm-sized retroperitoneal mass and showed the same findings during mass manipulation. For this patient, continuous manipulation of the mass seemed inevitable due to adhesion between the right adrenal gland and the mass in a narrow surgical field. The surgeon and anesthesiologists decided to cancel the surgical procedure and planned to perform a reoperation after alpha blockade therapy. Two weeks later, the tumor was uneventfully removed with small doses of vasoactive drugs. CONCLUSION: When an undiagnosed paraganglioma is suspected intraoperatively, reoperation after adequate preparation should be considered as an option to avoid fatal outcomes.

Nuclear receptor HR3 mediates transcriptional regulation of chitin metabolic genes during molting in Tribolium castaneum.

BACKGROUND: Chitin, a major component of insect cuticles, plays a critical role in insect molting and morphogenesis. Thus, coordination of chitin remodeling during insect development requires tight transcriptional control of the chitin metabolism genes involved in chitin synthesis, assembly and degradation. However, the molecular mechanism underlying transcriptional coordination of chitin metabolism genes during beetle development is not yet completely understood. RESULTS: We cloned the full-length cDNA encoding hormone receptor 3 (TcHR3) from Tribolium castaneum and showed a critical role of TcHR3 in modulating chitin metabolism gene expression during molting. Genome-wide transcriptome analysis of HR3-deficient old larvae using RNA sequencing analysis revealed a positive correlation between TcHR3 and transcription of chitin metabolism genes involved in chitin synthesis and degradation. In addition, HR3 overexpression significantly induced the gene promoter activity of N-acetylglucosaminidase 1 (NAG1) involved in chitin degradation and UDP-N-acetylglucosamine pyrophosphorylase 1 (UAP1) involved in chitin synthesis. Chromatin immunoprecipitation analysis revealed that HR3 could directly bind to HR3-response element of NAG1 and UAP1 promoters. Finally, HR3-deficient late instar larvae and prepupae exhibited defects in larval-larval and larval-pupal molting, respectively, leading to eventual larval death because developing larvae were trapped inside the old cuticle as a result of abnormal chitin metabolism. CONCLUSION: TcHR3 is a transcriptional regulator of chitin metabolic genes for molting of T. castaneum. Controlling the molting system by TcHR3 might be a new management strategy for selective control of red flour beetle infestation. © 2022 Society of Chemical Industry.

Nuclear receptor HR96 up-regulates cytochrome P450 for insecticide detoxification in Tribolium castaneum.

BACKGROUND: Red flour beetle, Tribolium castaneum (T. castaneum), is a major agricultural pest that causes significant damage to stored grains and products. Although hormone receptor 96 (HR96) is known to be the single ortholog corresponding to mammalian constitutive androstane receptor and pregnane X receptor, the structural features of Tribolium HR96 (TcHR96) and its role in insecticide-mediated transcription control of cytochrome P450 enzyme genes in T. castaneum have not been elucidated yet. RESULTS: We cloned full-length complementary DNA encoding TcHR96 and revealed the role of TcHR96 in transcriptional control of cytochrome P450 enzyme genes. Interestingly, genome-wide transcriptome analysis of HR96-deficient beetles using RNA sequencing showed a positive correlation between TcHR96 and gene transcription of metabolizing enzymes involved in phase I detoxification processes. Moreover, TcHR96 overexpression significantly increased the promoter activity of genes encoding phase I P450 enzymes such as CYP4Q4, CYP4G7, CYP4BR3, and CYP345A1. Chromatin immunoprecipitation analysis showed that TcHR96 could directly bind to the promoter of gene encoding CYP345A1, an enzyme for metabolizing insecticides in T. castaneum. Furthermore, imidacloprid, a neonicotinoid insecticide, significantly increased gene expression of phase I P450 enzymes in old larvae of T. castaneum, which were reversed by TcHR96 knockdown. Finally, TcHR96 knockdown significantly decreased the resistance of old larvae to imidacloprid concomitant with reduction of imidacloprid-mediated phase I P450 enzyme gene expression. CONCLUSION: TcHR96 plays a major role in transcriptional control of P450 enzyme for imidacloprid detoxification. Controlling TcHR96 might facilitate the regulation of insecticide tolerance in T. castaneum, thus providing a promising new strategy to manage pest beetle populations. © 2021 Society of Chemical Industry.

Prevalence, distribution, enterotoxin profiles, antimicrobial resistance, and genetic diversity of Bacillus cereus group isolates from lettuce farms in Korea.

Lettuce wraps are popular in Korean cuisine for their high nutritional value and versatility as healthy additions to multiple dishes. Microbial contamination of lettuce is a major concern, as lettuce is consumed fresh without cooking. Among foodborne pathogens, the spore-forming, facultative anaerobic bacterium, Bacillus cereus is one of the frequently detected pathogen in lettuce in Korea. In this study, we investigated the prevalence and distribution of Bacillus cereus strains in lettuce production farms and further evaluated the enterotoxin gene profiles, antibiotic susceptibility, multidrug resistance pattern, and genetic differences among the B. cereus group isolates. Of the 140 samples isolated from 10 lettuce production farms, 30 samples (21.42%) were positive for B. cereus in which 19 (31.6%) and 10 (23.25%) were from soil and lettuce, respectively. The enterotoxin patterns A (hblCDA, nheABC, entFM, and cytK genes) and B (hblCDA, nheABC, and entFM genes) accounted for 50% and 20% of all the isolates, whereas the emetic gene cesB was not detected in any of the B. cereus group isolates. Antibiotic susceptibility testing of the B. cereus group isolates revealed that all the strains were predominantly resistant to ß-lactam antibiotics except imipenem and generally susceptible to most of the non ß-lactam antibiotics, including gentamycin, streptomycin, chloramphenicol, and tetracycline. ERIC-PCR and MLST analysis revealed high genetic diversity among the 30 B. cereus group isolates, which belonged to 26 different sequence types (STs) and seven new STs. Moreover, isolates with identical STs exhibited similar patterns of antibiotic resistance and enterotoxin profiles. Results of this study indicate a high prevalence of B. cereus group isolates in lettuce production farms in the Republic of Korea.

Preservation of language function by mapping the arcuate fasciculus using intraoperative corticocortical evoked potential under general anesthesia in glioma surgery.

OBJECTIVE: Intraoperative language mapping under general anesthesia is imperative for brain tumor surgery because awake surgery is not always feasible. Monitoring corticocortical evoked potential (CCEP) is known to be a useful method for tracking neuronal connectivity and localizing functional areas. The authors evaluated the clinical benefit of intraoperative CCEP monitoring for language function preservation in patients undergoing glioma surgery. METHODS: Between January 2019 and June 2021, the authors performed a total of 29 consecutive glioma surgeries using CCEP monitoring under general anesthesia because of a risk of speech impairment; these were analyzed. Language area mapping was implemented by the anterior language area to posterior language area CCEP method for arcuate fasciculus mapping, and tumor resection was performed while avoiding the localized language areas. Language function before and after surgery was evaluated by the Controlled Oral Word Association Test (COWAT). RESULTS: Intraoperative CCEP was successfully monitored in 25 patients (86.2%), and a valid signal was undetectable in the other 4 patients. Language function evaluation was possible before and after surgery in a total of 20 patients. Overall, the preservation rate of language function was 65.0%, and the deterioration rate was 35.0% after tumor resection with CCEP monitoring. Among those 8 patients with preoperative COWAT scores ≥ 18, 5 patients (62.5%) successfully preserved their language function, with COWAT scores > 18 after tumor resection. Among the 12 patients with preoperative deteriorated language function (COWAT score < 18), 8 patients (66.7%) showed improvement or preserved language function after surgery. CONCLUSIONS: Intraoperative CCEP monitoring of the arcuate fasciculus is an acceptable technology for the preservation of language function under general anesthesia in glioma surgery in patients in whom awake surgery is not feasible.

Clinical features of late onset non-infectious pulmonary complications following pediatric allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Late onset non-infectious pulmonary complications (LONIPCs) are major causes of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We evaluated the incidence and the outcomes of LONIPCs in children who underwent allo-HSCT. METHODS: Data for 143 children who underwent allo-HSCT at Asan Medical Center between April 2002 and April 2009 were reviewed, and the 127 who survived more than three months were enrolled. RESULTS: Eleven (8.7%) developed LONIPCs at a median eight months (range 3-14 months) after allo-HSCT, presenting with cough and dyspnea. Six had bronchiolitis obliterans and five had idiopathic pneumonia syndrome. FVC declined more significantly in LONIPC than in non-LONIPC patients three months after HSCT. A significant risk factor for the development of LONIPCs was chronic graft-versus-host disease (GVHD) (p = 0.002). At a median follow-up of 36 months, the three-yr overall survival rate in LONIPC patients was significantly lower than that of non-LONIPC patients (37.4% vs. 72.7%, p = 0.02). The major cause of death was respiratory failure. CONCLUSIONS: Along with chronic GVHD, deterioration of pulmonary function at three months after HSCT may help in the early identification of patients at risk of subsequent LONIPCs. Considering the poor prognosis of LONIPC, strategies should be aimed at their prevention.

Prognostic implications of serum alpha-fetoprotein response during treatment of hepatoblastoma.

BACKGROUND: We evaluated the outcomes and prognostic factors, especially serum levels of alpha-fetoprotein (AFP) and their changes during the treatment of hepatoblastoma (HB). PROCEDURE: We retrospectively analyzed the medical records of 43 consecutive children with HB treated at a single institution between 1991 and 2010. RESULTS: Of 43 patients, 5 (12%) underwent primary tumor resection at diagnosis and 38 (88%) received preoperative chemotherapy. Of those 38 patients, 7 (16%) died of progressive disease during preoperative chemotherapy, and 31 (72%) underwent curative operations, including 5 who underwent liver transplantation, after a median 4 cycles of chemotherapy (range, 3-14 cycles). The 5-year overall survival and disease-free survival rates were 62.1 ± 8.3% and 65.6 ± 7.6%, respectively. AFP >263,000 ng/mL at diagnosis, a decline of <1 log in AFP levels after the first cycle of chemotherapy, preoperative AFP levels in the highest tertile, and postoperative AFP levels in the highest tertiles were significantly associated with treatment failure. Age younger than 1 year at diagnosis, thrombocytosis at diagnosis, and early PRETEXT (pretreatment extent of disease) stage were significantly associated with better survival outcomes, whereas gender and metastasis were not. Multivariate analysis showed that high level of preoperative AFP was an independent predictor of treatment failure. CONCLUSIONS: Serial monitoring of changes in AFP levels during the treatment, especially perioperative changes, may help identify favorable and poor responders to chemotherapy. Alternative treatment, such as liver transplantation, should be considered for poor responders.

Pancreatic neoplasms in childhood and adolescence.

Pancreatic neoplasms are rare in children and adolescents; thus, our understanding of these tumors is still quite limited. We retrospectively reviewed clinical features and outcomes of all patients below 18 years of age with pancreatic neoplasms who were treated at Asan Medical Center between December 1994 and March 2010. Thirty-two patients were identified. Abdominal pain was the most common symptom. The median duration of diagnostic delay was 21 days. Nineteen patients were diagnosed with solid pseudopapillary tumors, 3 with lymphomas, 2 with pancreatoblastomas, 2 with poorly differentiated carcinomas, 2 with acinar cell cancers, 2 with endocrine tumors, 1 with peripheral (primitive) neuroectodermal tumor, and 1 with hemangioendothelioma. Gross complete resection of the primary tumor was achieved in 24 patients (75%), and 8 patients (25%) received chemotherapy. At a median follow-up of 34 months, the 5-year overall survival rate was 92.0 ± 5.5%. On multivariate analysis, histologic type was the only factor significantly predictive of survival (P=0.009). Patients with poorly differentiated carcinoma showed the worst survival probability. In cases of solid pseudopapillary tumors, surgical resection was generally curative and the prognosis was excellent. Patients with other malignant tumors, however, may require therapeutic strategies other than surgery.

Favorable outcomes after allogeneic hematopoietic stem cell transplantation in children with high-risk or advanced acute myeloid leukemia.

The role of allogeneic hematopoietic stem cell transplantation (HSCT), including transplantation from an alternative donor (AD), has not been clearly defined for children with high-risk or advanced acute myeloid leukemia (AML). We retrospectively reviewed outcomes in 29 children (median age at HSCT, 6.7 y; range, 1.0-16.2 y) with high-risk or advanced AML who underwent allogeneic HSCT at the Asan Medical Center between 1998 and 2008. Donors included a matched sibling donor (MSD) for 7 patients (24%), an unrelated volunteer for 21 patients (72%), and a haploidentical mother for 1 patient (3%). The 3-year estimates of overall survival and event-free survival (EFS) were 77% [95% confidence interval (CI), 65%-99%] and 70% (95% CI, 57%-93%), respectively, whereas the cumulative incidences of relapse and transplant-related mortality were 33% (95% CI, 5%-58%) and 7% (95% CI, 0%-44%), respectively. The 3-year EFS rates did not differ between MSD and AD HSCT. Univariate analysis showed that age ≥ 10 years at diagnosis was the only factor associated with poorer EFS. Development of acute graft-versus-host disease predicted a significantly lower incidence of relapse. These findings may provide further evidence that allogeneic HSCT is a curative therapy for children with high-risk or advanced AML, and suggest the efficacy of AD transplantation.

A novel mutation and unusual clinical features in a patient with immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome.

UNLABELLED: We report a patient with immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome with a novel splicing mutation of the FOXP3 gene. The patient is a boy, born at 39 + 2 weeks gestation with a birth weight of 3,280 g. The family history was unremarkable. He was well until 11 months of age, when he was diagnosed with type 1 diabetes mellitus. The level of urine C-peptide was 0.58 µg/day (normal range, 44-116 µg/day). Glutamic acid decarboxylase autoantibody was not detected, but a high level of anti-insulin antibody (50 IU/mL; normal range, <5 IU/mL) was noted. This patient presented with unusual clinical features, including pure red cell aplasia, membranous glomerulopathy, and posterior reversible encephalopathy syndrome after a vaccination against influenza A H1N1 virus. The diagnosis of IPEX was made when the patient was 11 years old, which is quite late compared with typical cases. CONCLUSION: Although IPEX syndrome is usually a disease of infancy, it should not be ruled out solely on the basis of age. IPEX presentation is so variable that it should be suspected in a male child with one or more autoimmune disorders and severe infections.

Lineage switch at relapse of childhood acute leukemia: a report of four cases.

Lineage switch in acute leukemia is an uncommon event at relapse, and therefore rarely reported in the literature. Here, we have described the clinical laboratory features of four cases in which the cell lineage switched from acute lymphoblastic leukemia (ALL) to acute myeloid leukemia (AML). One patient was initially diagnosed with B-ALL, switched to T-ALL at the first relapse, and eventually, AML at the second relapse. A lineage switch represented either relapse of the original clone with heterogeneity at the morphologic level or emergence of a new leukemic clone. Further sequential phenotypic and cytogenetic studies may yield valuable insights into the mechanisms of leukemic recurrence, with possible implications for treatment selection.