Current Prevalence of the crpP Gene in Carbapenemase-Producing Pseudomonas aeruginosa Blood Isolates in Korea / 대한임상미생물학회지

Background@#Recently, CrpP enzymes have been described as a novel cause of ciprofloxacin resistance. The crpP gene encodes a novel protein that specifically confers resistance to ciprofloxacin through an adenosine triphosphate-dependent mechanism that phosphorylates the antimicrobial. In this study, the current prevalence of the crpP gene in carbapenemaseproducing Pseudomonas aeruginosa blood isolates was evaluated. @*Methods@#During the study of the Antimicrobial Resistance Surveillance System in Korea, 22 blood isolates of carbapenemase-producing P. aeruginosa were collected from nine general hospitals and two nursing homes in the year 2020. Resistance genes and phylogenic trees were analyzed with the whole genome sequencing data. @*Results@#A total of 11 P. aeruginosa blood isolates coharbored the crpP and carbapenemase genes (nine IMP-6 producers and two GES-5-producers). Nine NDM-1-producers coharbored aac(6')-Ib-cr and qnrVC1 . One GES-9-producer also carried aac(6')-Ib-cr, and one NDM-1-producer also carried qnrVC1. The phylogenic tree showed no epidemiologic link among the 22 carbapenemase-producing P. aeruginosa isolates. @*Conclusion@#This is the first report on the current prevalence of the crpP gene in carbapenemaseproducing P. aeruginosa blood isolates in Korea.

Heart rate recovery and diastolic blood pressure ratio on the treadmill test predict an induction and recurrence of vasovagal syncope

BACKGROUND/AIMS@#The induction and recurrence of syncope is a concerning situation that could be unpredicted in the vasovagal syncope (VVS). We investigated a simple predictor for the induced and recurrent VVS during Head-Up table-tilt Test (HUT) and clinically follow-up.@*METHODS@#The 143 consecutive patients with VVS (age 31 ± 19 years, 33 male) who referred by a cardiologist or neurologist and had undergone an echocardiogram, HUT, and a treadmill exercise test (TMT) were recruited and clinically follow-up. Patients were divided into two groups based on the result of HUT and TMT. The data was analyzed and compared between VVS patients and control 141 patients without VVS who were enrolled in the same study period (age 40 ± 5 years, 117 male).@*RESULTS@#The heart rate recovery (HRR), recovery systolic blood pressure (RecSBP), recovery diastolic blood pressure (RecDBP), HRR/RecSBP and HRR/RecDBP were significantly different between controls and VVS during the TMT. Within VVS, even if, baseline characteristics were similar between negative and positive HUT (n = 92 vs. n = 51). HRR (31 ± 10 vs. 35 ± 10), HRR/RecSBP (0.24 ± 0.09 vs. 0.28 ± 0.09) and HRR/RecDBP (0.49 ± 0.18 vs. 0.58 ± 0.19) were significantly different between negative and positive HUT results. Especially, HRR/RecSBP and HRR/RecDBP were significantly correlated with induced syncope with a sensitivity and specificity ([60%, 83%] cut-off, 0.31; [72%, 80%] cut-off, 0.63). In the Cox regression, HRR/RecDBP were significantly associated with recurrence of VVS with hazard ratio of 3.29 (confidence interval, 0.95 to 11.3; p = 0.049).@*CONCLUSIONS@#HRR/RecDBP may be a useful predictor for induction during HUT and recurrence during follow-up in the VVS.

Association between Physical Fitness and Cardiometabolic Risk of Children and Adolescents in Korea / 가정의학회지

BACKGROUND: This study aimed to investigate the association between physical fitness and cardiometabolic health of Korean children and adolescents. METHODS: In total, 168 participants (89 boys and 79 girls) aged 10–16 years were recruited for the Intervention for Childhood and Adolescent Obesity via Activity and Nutrition Study in 2016. The subjects were categorized into two groups using the definition of metabolic syndrome by the International Diabetes Federation: metabolically unhealthy (with at least two of the five criteria) and healthy groups (with less than one criterion). Correlation analysis of the participants' general characteristics was performed. Odds ratios (ORs) of physical fitness for cardiometabolic risk were evaluated via logistic regression. RESULTS: Metabolically unhealthy children showed greater weight, height, and body mass index, higher Children's Depression Inventory score, and longer screen time than did the metabolically healthy children. Metabolically healthy children showed greater upper and lower extremity muscular strength than did the metabolically unhealthy children (P=0.04 and P<0.001, respectively). In the multiple logistic regression analysis, lower extremity muscle strength was inversely related to the clustered cardiometabolic risk of the children and adolescents with or without adjustment for confounders (OR, 4.32; 95% confidence interval [CI], 1.87–9.97; OR, 7.64; 95% CI, 1.55–37.74, respectively). CONCLUSION: Physical fitness, especially lower extremity muscle strength, is significantly inversely associated with individual and clustered cardiometabolic risks in Korean children and adolescents.

Predictors of acute myocarditis in complicated scrub typhus: an endemic province in the Republic of Korea

BACKGROUND/AIMS: Scrub typhus is known as a self-limited infectious disease. Cardiac complication is uncommon and usually not life-threatening. Until now, few cases of fulminant myocarditis by scrub typhus have been reported. So, we investigated incidence and predictors of acute myocarditis in severe scrub typhus. METHODS: We retrospectively reviewed 89 patients among 91 scrub typhus confirmed patients who examined an echocardiogram and cardiac biomarkers from 2005 to 2015 in the intensive care unit at our hospital. We excluded two patients who didn’t have electrocardiography. Patients were divided into two groups and compared between scrub typhus with (n = 13) and without (n = 76) acute myocarditis. RESULTS: Age, sex, and underlying diseases were similar between the groups. The existence of eschar and duration of general ache and fever were similar between the groups. However, patients with acute myocarditis had more elevated total bilirubin, high incidence of ST elevations and paroxysmal atrial fibrillation (PAF) than those without acute myocarditis. Receiver operating characteristic analysis showed that the PAF was a predictor of myocarditis with a sensitivity of 70% and specificity of 84%. Predictive power of combination of ST-segment elevation and PAF was significantly associated with myocarditis in the multivariate analysis (odds ratio, 1.57; 95% confidence interval [CI], 1.21 to 11.7; p = 0.041) and area under the curve was 0.947 (95% CI, 0.878 to 0.983; p < 0.001). CONCLUSIONS: Acute myocarditis with scrub typhus may be more common than previously reported. Patients with high bilirubin and PAF are at increased risk of acute myocarditis with scrub typhus. These patients warrant closer follow-up and echocardiogram would be needed.

Comparison of Rhythm and Rate Control Strategies for Stroke Occurrence in a Prospective Cohort of Atrial Fibrillation Patients

PURPOSE: Comparisons of rhythm and rate control strategies for stroke prevention in patients with atrial fibrillation (AF) are still inconclusive. We compared differences in clinical outcomes between the rhythm and rate control strategies. MATERIALS AND METHODS: The COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry prospectively enrolled 6000 patients who were treated for AF using real-world guideline adherence at multiple referral centers. In total, 2508 (41.8%) patients were clinically followed up for over six months. Of these, 1134 (45.2 %) patients treated by rhythm control and 1374 (54.8 %) patients treated by rate control were analyzed for clinical outcomes, including stroke and cardiovascular outcomes. RESULTS: Among all patients (age, 68±10 years; male, 62.4%), those treated with the rhythm control strategy were significantly younger, had more symptomatic paroxysmal AF, and a shorter AF duration, and were less likely to have diabetes, renal dysfunction, and heart failure, compared to those treated with the rate control strategy (CHA₂DS₂-VASc score 2.4±1.5 vs. 3.1±1.7, p < 0.001). Even though oral anticoagulation was similarly prescribed in both groups, occurrence of stroke was less likely to occur in the rhythm control strategy group (0.0% vs. 0.7%, p=0.015). Multivariate Cox hazard regression showed that only age, especially more than 75 years old, were significantly correlated with the occurrence of stroke, regardless of the strategy used for treatment. CONCLUSION: In this prospective AF cohort, compared with the rate control strategy, the rhythm control strategy was associated with fewer cardiovascular events and strokes in a short-term period.

Diastolic Dysfunction Induced by a High-Fat Diet Is Associated with Mitochondrial Abnormality and Adenosine Triphosphate Levels in Rats

BACKGROUND: Obesity is well-known as a risk factor for heart failure, including diastolic dysfunction. However, this mechanism in high-fat diet (HFD)-induced obese rats remain controversial. The purpose of this study was to investigate whether cardiac dysfunction develops when rats are fed with a HFD for 10 weeks; additionally, we sought to investigate the association between mitochondrial abnormalities, adenosine triphosphate (ATP) levels and cardiac dysfunction. METHODS: We examined myocardia in Wistar rats after 10 weeks of HFD (45 kcal% fat, n=6) or standard diet (SD, n=6). Echocardiography, histomorphologic analysis, and electron microscopy were performed. The expression levels of mitochondrial oxidative phosphorylation (OXPHOS) subunit genes, peroxisome-proliferator-activated receptor gamma co-activator-1alpha (PGC1alpha) and anti-oxidant enzymes were assessed. Markers of oxidative stress damage, mitochondrial DNA copy number and myocardial ATP level were also examined. RESULTS: After 10 weeks, the body weight of the HFD group (349.6+/-22.7 g) was significantly higher than that of the SD group (286.8+/-14.9 g), and the perigonadal and epicardial fat weights of the HFD group were significantly higher than that of the SD group. Histomorphologic and electron microscopic images were similar between the two groups. However, in the myocardium of the HFD group, the expression levels of OXPHOS subunit NDUFB5 in complex I and PGC1alpha, and the mitochondrial DNA copy number were decreased and the oxidative stress damage marker 8-hydroxydeoxyguanosine was increased, accompanied by reduced ATP levels. CONCLUSION: Diastolic dysfunction was accompanied by the mitochondrial abnormality and reduced ATP levels in the myocardium of 10 weeks-HFD-induced rats.

Torsades de Pointes during Treatment of Tachycardia-Induced Cardiomyopathy / 대한구급학회지

Tachycardia-induced cardiomyopathy is caused by persistent tarchyarrhythmias and is characterized by ventricular systolic dysfunction and congestive heart failure. Tachycardia-induced cardiomyopathy is usually reversible via treatment. The cornerstone in the management of disease in these patients is to achieve a normal heart rate. We report a torsades de pointes during treatment of tachycardia-induced cardiomyopathy. Intravenous magnesium sulfate and potassium were administrated, but torsades de pointes was repeated. After overdrive right ventricular pacing, torsades de pointes was terminated. Careful monitoring of the QT interval and serum electrolyte and drug levels in such patients is warranted during treatment of tachycardia-induced cardiomyopathy.

Thoracic Endovascular Aortic Repair with the Chimney Technique for Blunt Traumatic Pseudoaneurysm of the Aortic Arch in a No-Option Patient

A 42-year-old man was involved in a motor vehicle collision. Imaging studies revealed the presence of a post-traumatic aortic pseudo-aneurysm (about 34x26 cm) arising from the descending thoracic aorta at the level of the left subclavian artery (LSA), prone to rupture. Thoracic endovascular aneurysm repair (TEVAR) was the only feasible option due to his poor overall medical status. In this case, LSA needed to be covered in order to extend the proximal landing zone. Eventually, modified TEVAR was successfully performed by means of the chimney technique to preserve flow to the LSA and to prevent flow into the pseudoaneurysmal sac.

Hybrid Approach for the Treatment of Thoracic Aortic Arch Aneurysm in a Patient With Chronic Obstructive Lung Disease and Retrosternal Adhesion

A 73-year-old woman with a history of chronic hypertension and severe chronic obstructive pulmonary disease, presented to a district general hospital with thoracic pain in a profound state of shock. She was diagnosed with cardiac tamponade, severe mitral regurgitation, and Stanford type A (Debakey type I) intramural hematoma. Her ascending aorta was of a significant size and therefore emergent repair was done to replace the ascending aorta and mitral valve. After 6 months, an increased aneurysmal size of 6.0 cm was observed in a follow up contrast-enhanced computed tomography angiography. The patient was successfully treated by a staged hybrid procedure involving initial supra-aortic reconstruction.

Characteristics of Double-Chambered Right Ventricle in Adult Patients

BACKGROUND/AIMS: This study evaluated the clinical features of double-chambered right ventricle (DCRV) in adults. Most cases of DCRV are diagnosed and treated during childhood. Consequently, very few reports include cases in which its clinical characteristics are evident in adults. METHODS: We reviewed the clinical data for 10 adult patients (age > or = 18 years) with DCRV. RESULTS: Electrocardiogram showed right ventricular hypertrophy in 3 DCRV patients. All cases were associated with ventricular septal defect (VSD; 7 for perimembranous, 2 for muscular outlet, and 1 for the subarterial type). Surgical correction was done for 7 DCRV patients all of whom survived operations. Their follow-up echocardiogram showed the pressure gradient in their right ventricle was significantly decreased from 69.4 +/- 17.2 mmHg preoperatively to 10.2 +/- 5.0 mmHg postoperatively (p < 0.05). In the short-term follow-up, there was no significant increase in the pressure gradient in the right ventricle. CONCLUSIONS: There are lots of cases of DCRV that are not diagnosed accurately in adults. In our experience, all DCRV cases had VSD and surgical correction of these cases showed excellent results. Therefore, accurate diagnosis of DCRV is necessary so that DCRV is not overlooked and operations are enabled within an appropriate time.

Expression and Antibody Production of Japanese Encephalitis Virus RNA Polymerase (NS5) Protein

Japanese encephalitis virus (JEV), a member of mosquito-borne flaviviruses, is the leading cause of viral encephalitis in a large geographic area of Southeast Asia and Australia. JEV contains a single-stranded positive-sense RNA genome, which encodes its own RNA-dependent RNA polymerase (NS5) that is required for genomic RNA replication. In this study, we have described a pair of mouse antisera specific to the N- or C-terminal region of the NS5. Initially, two hydrophilic regions corresponding to the N-terminus and C-terminus of the NS5 protein were individually amplified by reverse transcription-PCR from the genomic RNA of JEV K87P39 strain. The amplified DNA fragments were cloned into a prokaryotic expression vector, pGEX-4T-1; the resulting constructs were used for the expression of GST fusion proteins, designated GST/NS5N and GST/NS5C, in E. coli BL-21 strain. Following immunization of three BALB/c mice with each of the purified GST/NS5N and GST/NS5C, we obtained two pools of the antisera, specifically recognizing the ~103-kDa NS5 and several smaller NS5-related proteins in BHK-21 and Vero cells infected with JEV K87P39 strain. Overall, we have successfully expressed the N- and C-terminal regions of JEV NS5 fused to the C-terminus of GST and generated the mouse antisera capable of recognizing the NS5 and its related proteins in JEV-infected cells. This would provide a valuable reagent for the study of JEV NS5 in the viral life cycle.

Brucella Endocarditis with Splenic Abscess: A Report of the First Case Diagnosed in Korea

Human brucellosis has a broad spectrum of clinical manifestations, which includes endocarditis, a focal complication that is uncommon yet responsible for the majority of associated deaths. The most successful treatment outcomes of Brucella endocarditis have been reported with usage of both antimicrobial agents and surgery. However, there are few reports on the treatment of Brucella endocarditis using antibiotics only. We report the first case in Korea of Brucella endocarditis with aortic valve vegetations and an accompanying splenic abscess, which were treated successfully with antibiotic therapy alone.

A case of arrhythmogenic right ventricular cardiomyopathy/dysplasia involving the left ventricle / 대한내과학회지

Arrhythmogenic right ventricular cardiomyopathy (ARVC)/dysplasia is characterized by fibro-fatty replacement of the right ventricular myocardium. A 19-year-old soldier was admitted with sudden cardiac arrest that presented as ventricular fibrillation requiring cardiopulmonary resuscitation. His electrocardiogram (ECG) showed normal sinus rhythm with inverted T waves from leads V1 to V4 and isolated premature ventricular beats with a left bundle branch block (LBBB) pattern. Echocardiography showed that the right ventricle was enlarged with apical trabecular formation. The coronary angiogram was normal. Cardiovascular magnetic resonance imaging (MRI) showed thinning and fatty substitution of both the right and left ventricular free walls. Ventricular tachycardia (LBBB pattern) occurred frequently despite anti-arrhythmic drug treatment. His drug-resistant ventricular tachycardia was treated with an implanted cardiac defibrillator. Left ventricle involvement in ARVC is less common and more severe. Cardiac MRI is considered the best imaging technique for evaluating the right ventricle and diagnosing ARVC.

Intracellular Localization of the Porcine Reproductive and Respiratory Syndrome Virus Nucleocapsid Protein

Porcine reproductive and respiratory syndrome virus (PRRSV) is a small enveloped, positive-stranded RNA virus belonging to the family Arteriviridae. It causes the porcine reproductive and respiratory syndrome in swine. The virus has 7 structural proteins: Of the seven, the N protein is the nucleocapsid that comprises a core of the virus particle. We have expressed the N protein of PRRSV PL97-1/LP1 strain using a heterologous gene expression vector derived from Sindbis virus, called pSinrep5. Immunofluorescence analysis showed that the N proteins were mainly found in the cytoplasm as well as in the nucleus of BHK-21 cells transfected with pSinrep5-N-derived RNA. Moreover, expression of the N protein did not change the incompetence of RNA replication of Mutant/nt14900 that lacks a 3' cis-acting replication element and the efficiency of RNA replication of Mutant/nt14800 that has a low level of RNA replication. Overall, our findings are consistent with previous results and help to understand a role of the N protein in PRRSV biology.

Three cases of right coronary anomaly confirmed by multi-detector computed tomography / 대한내과학회지

Congenital anomaly of the right coronary artery is a very rare disease. It can cause syncope, angina pectoris, acute myocardial infarction, ventricular fibrillation and sudden cardiac death during exercise in the young population. The dominancy of the coronary artery, and the site, shape and pathway of the right coronary artery seems to play a key role in developing those above mentioned events. Especially, it has been known that the right coronary artery that courses between the aorta and pulmonary trunk increases the risk of sudden death. Therefore, precise evaluation is needed to diagnose the presence and type of coronary artery anomaly. Nowadays, multi-detector computed tomography is used to diagnose coronary anomalies and this provides clear images of coronary anomaly in a safe and noninvasive way. We report here on three cases of right coronary anomaly that coursed between the aorta and pulmonic trunk, and this was confirmed by multi-detector computed tomography.

The Feasibility of 5-French Transradial Coronary Intervention, as Compared with a 6-French Approach, for Treating Chronic Total Occlusion

BACKGROUND AND OBJECTIVES: Recent studies have shown that transradial coronary intervention (TRI) is feasible for percutaneous revascularization of chronic total occlusion (CTO). We investigated the feasibility and safety of using a 5-French catheter (5F) TRI for CTO and we compared it with that of using a 6F catheter TRI. SUBJECTS AND METHODS: One hundred fifteen patients (117 lesions) who underwent TRI for CTO (TIMI 0 or 1 for more than 2 months) were prospectively registered in this study from April 2002 to July 2004 (54 patients for the 5F and 61 patients for the 6F). The clinical, angiographic and procedural characteristics were evaluated and compared between the 2 groups. RESULTS: No major difference was noted for the clinical characteristics between the 2 groups. Coronary angiography showed a shorter occlusion length (5F: 8.8+/-7.6 mm, 6F: 14.7+/-12.7, p=0.008) and a higher incidence of the tapered type of entry morphology (5F: 74%, 6F: 56%, p=0.042) in the 5F group. A deep-seating technique was used more often in the 5F group (5F: 83%, 6F: 51%, p<0.001). The procedural success rate was similar between the 2 groups (5F: 82%, 6F: 86%, p<0.54). The most common cause of procedural failure for both groups was failure to pass the guidewire. The occlusion duration, lesion length and lesion angulation were the statistically significant predictors of procedural failure. No major procedural or local complication was noted. Minor hematoma occurred in 2 patients and no radial artery occlusion was noted. CONCLUSION: A 5F catheter TRI may be feasible and safe to use for a selected group of CTO lesions.

5' and 3' cis-Acting RNA Elements Required for RNA Replication of Porcine Reproductive and Respiratory Syndrome Virus

Porcine reproductive and respiratory syndrome virus (PRRSV), a member of the genus Arterivirus in the family Arteriviridae, is the most important viral pathogens in swine industry worldwide. Here, we have investigated 5' and 3' cis-acting RNA elements required for PRRSV genome replication. Using the infectious PRRSV cDNA, we have manipulated the genomic RNA to generate mutant genomic RNAs, transfected these mutants into susceptible MARC-145 cells, and examined the competence of RNA replication. We found three genetic factors that were essential for viral replication. First, the cap structure present at the 5'-end of the genome was absolutely required for RNA replication. Secondly, polyadenylation of the genomic RNA at the 3'-end was also essential for RNA replication. Thirdly, approximately 100-nucleotide region just upstream of the N protein-coding region was crucial for genomic RNA replication. Taken together, our findings indicate that replication of PRRSV genomic RNA requires three important cis-acting RNA elements: 5' cap structure, 3' poly(A) motif, and an internal sequence of about 100 nucleotides. Further investigation is needed to elucidate the molecular mechanism(s) of how these elements act on PRRSV genome replication.

hVEGF121 transfection and animal model for in vivo angiogenesis / 대한내과학회지

BACKGROUND: This study was designed to prove the superiority of ACP vector containing ITR, and to establish animal model quantifying angiogenesis in vivo. METHODS: hVEGF121, therapeutic gene, was inserted to various vectors (pcDNA3.1, pcDNA 3.2, pActin, pDesm, pACP vector), and these vectors were transfected to various cells using FuGENE6. We cultured for 48hrs, and then quantified amounts of hVEGF121 of supernatants by ELISA. The long-term transfection was assessed for 14 days. Optimal condition of transfection was evaluated by change of the ratio of DNA to FuGENE6, amount of DNA, and confluence of cells. ACP-hVEGF121 was transfected to C2C12 and these transfected C2C12 cells were mixed with Matrigel, and then injected to C3H mouse subcutaneously. Seven days later, hemoglobin assay and pathology of Matrigel were reviewed for angiogenesis. RESULTS: The level of hVEGF121 gene expression using pACP vector was significantly higher than those of others. In 2 weeks culture study, pACP vector showed the highest gene expression and produced VEGF until 2 weeks. The highest gene expression was obtained when the concentration of DNA was 7 microgram, the confluence was up to 80% and the ratio of DNA to FuGENE6 was 1:3. The hemoglobin level in Matrigel of VEGF group was significantly higher than the one of the control group, and active angiogenesis was noted in the VEGF group. CONCLUSIONS: pACP vector might be an efficient vector for angiogenic gene delivery, and animal model using Matrigel and transfected C2C12 cell could be a useful tool for quantitative angiogenesis assay.

Spontaneous Closure of Iatrogenic Coronary Artery Fistula to Left Ventricle After Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

Cases of iatrogenic coronary artery fistulas draining into the left ventricle after surgical myectomy for hypertrophic obstructive cardiomyopathy have been published as sporadic reports. However, its management scheme and prognosis are not clear because of the low incidence. A 46-yr-old woman was hospitalized for evaluation of chest pain and shortness of breath for 3 months. Transthoracic echocardiographic examination showed typical hypertrophic obstructive cardiomyopathy with a peak pressure gradient of 71 mmHg across the left ventricular outflow tract. The patient underwent surgical septal myectomy. Postoperative color Doppler imaging revealed a diastolic blood flow from the interventricular septal myocardium to the left ventricular cavity, i.e. iatrogenic coronary artery fistula to the left ventricle. Ten days later, the fistula closed spontaneously which was diagnosed by transthoracic echocardiography and confirmed by coronary angiography.

Evidence for the Presence of a cis-acting Element in the Coding Region of the Japanese Encephalitis Virus Capsid Protein

Japanese encephalitis virus (JEV) is a member of mosquito-borne flaviviruses. To investigate whether there is a cis-acting genetic element in the coding region of the JEV C protein, which is required for viral replication, we generated four mutants by introducing a various size of deletions in each structural protein-coding region, designated as pJEV/Rep/deltaCC/LUC, pJEV/Rep/deltaC/LUC, pJEV/Rep/deltaprM/LUC, and pJEV/Rep/deltaE/LUC, of these, all replicons except for pJEV/Rep/deltaCC/LUC were competent in replication. Since pJEV/Rep/deltaCC/LUC is the same as pJEV/Rep/ deltaC/LUC except for an additional 5' deletion (nt 132~201) in the coding region of the C protein, this region appeared to be essential for RNA replication. This is consistent with the proposed cyclization sequence motif in the 5' region of the C gene, which has been recently shown to be required for replication in other mosquito-borne flaviviruses such as DV, YFV, KUN, and WNV. Thus, our results suggest that a cis-acting genetic element in the coding region of the JEV C protein may play an important role in RNA replication. This study will facilitate the current understanding of JEV RNA replication.