Publications by authors named "Chang-Hwan Park"

226 Publications

Underwater endoscopic mucosal resection of an incompletely resected superficial non-ampullary duodenal epithelial neoplasm using the loop-and-let-go technique: A case report.

Medicine (Baltimore) 2021 Jan;100(2):e24041

Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital and Medical School, Gwangju, South Korea.

Rationale: Endoscopic resection of superficial non-ampullary duodenal epithelial neoplasm (SNADEN) is a challenging procedure owing to the high recurrence rate and considerable incidence rate of adverse events.

Patient Concerns: SNADEN accidentally found during a medical examination in a 56-year-old man.

Diagnosis: The patient was diagnosed as having a 20-mm-sized flat elevated SNADEN at the superior duodenal angle.

Interventions: First, we tried to perform conventional EMR (CEMR). However, the submucosal injection interrupted the endoscopic view and did not provide enough space for CEMR because of its angulated location. Therefore, we chose to perform endoscopic resection using the "loop-and-let-go" technique. Follow-up duodenoscopy after 2 days revealed post CEMR ulcer with suspicious remnant lesion. Underwater endoscopic mucosal resection (UEMR) was successfully performed 3 months after the first session of endoscopic resection.

Outcomes: Complete endoscopic en bloc resection and histological complete resection were achieved with UEMR. Follow-up duodenoscopy revealed no recurrence.

Lessons: Step-by-step endoscopic treatment with UEMR following loop-and-let-go technique may be a good strategy for SNADEN over 20-mm in diameter.
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http://dx.doi.org/10.1097/MD.0000000000024041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808504PMC
January 2021

Malignant potential of small pancreatic neuroendocrine neoplasm and its risk factors: A multicenter nationwide study.

Pancreatology 2021 Jan 1;21(1):208-214. Epub 2020 Dec 1.

Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea. Electronic address:

Background: Pancreatic neuroendocrine neoplasms (PNENs) show heterogeneous biological behavior, and most small PNENs show indolent features. Consequently, selected cases can be considered for observation only, according to the National Comprehensive Cancer Network guideline, however, supporting clinical evidence is lacking. We investigated the clinical course of small PNENs and their risk factors for malignant potential.

Methods: A total of 158 patients with small pathologically confirmed PNENs ≤2 cm in initial imaging were retrospectively enrolled from 14 institutions. The primary outcome was any metastasis or recurrence event during follow-up.

Results: The median age was 57 years (range, 22-82 years), and 86 patients (54%) were female. The median tumor size at initial diagnosis was 13 mm (range, 7-20 mm). PNENs were pathologically confirmed by surgery in 137 patients and by EUS-guided fine needle aspiration biopsy (EUS-FNAB) in 21 patients. Eight patients underwent EUS-FNAB followed by surgical resection. The results of WHO grade were available in 150 patients, and revealed 123 grade 1, 25 grade 2, and 2 neuroendocrine carcinomas. A total of 145 patients (92%) underwent surgical resection, and three patients had regional lymph node metastasis. During the entire follow-up of median 45.6 months, 11 metastases or recurrences (7%) occurred. WHO grade 2 (HR 13.97, 95% CI 2.60-75.03, p = 0.002) was the only predictive factor for malignant potential in multivariable analysis.

Conclusions: WHO grade is responsible for the malignant potential of small PNENs ≤2 cm. Thus, EUS-FNAB could be recommended in order to provide early treatment strategies of small PNENs.
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http://dx.doi.org/10.1016/j.pan.2020.11.016DOI Listing
January 2021

Current Trends in the Management of Pancreatic Cystic Neoplasms in Korea: A National Survey.

Korean J Intern Med 2020 Sep 29. Epub 2020 Sep 29.

Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea.

Background/aims: The study aimed to investigate the current practice patterns in the management of pancreatic cystic neoplasms in Korea.

Methods: An electronic survey was systematically distributed by email to members of the Korean Pancreatobiliary Association from December 2019 to February 2020.

Results: In total, 115 (110 gastroenterologists, 5 surgeons) completed the survey, 72.2% of whom worked in a tertiary/academic medical center. Most (65.2%) followed the 2012/2017 International Association of Pancreatology guidelines for the management of pancreatic cystic neoplasms. A gadolinium-enhanced magnetic resonance imaging/magnetic resonance cholangiopancreatography was the most common first-line diagnostic modality (42.1%), but a contrast-enhanced computed tomography scan was preferred as a subsequent surveillance tool (58.3%). Seventy-four percent of respondents routinely performed endoscopic ultrasound-guided fine needle aspiration for pancreatic cystic neoplasms with suspicious mural nodules. Endoscopic ultrasound guided fine needle aspiration cytology (94.8%) and cystic fluid carcinoembryonic antigen (95.7%) were used for cystic fluid analysis. Most (94%) typically recommended surgery in patients with high-risk stigmata, but 18.3% also considered proceeding with surgery in patients with worrisome features. Most (96.5%) would continue surveillance of pancreatic cystic neoplasms for more than five years.

Conclusions: According to this survey, there was variability in the management of pancreatic cystic neoplasms among the respondents. These results suggest that the development of evidence-based guidelines for pancreatic cystic neoplasms that fit the Korean practice is needed to create an optimal approach to the management of pancreatic cystic neoplasms.
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http://dx.doi.org/10.3904/kjim.2020.452DOI Listing
September 2020

Underwater endoscopic mucosal resection for neoplasms in the pyloric ring of the stomach: Four case reports.

World J Clin Cases 2020 Jul;8(14):3050-3056

Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea.

Background: Tumors located in the pylorus are technically more complex to resect by endoscopic resection, as the anatomical characteristics of this region can affect the adequate assessment of margins and performance of the procedure. We reported the results of underwater endoscopic mucosal resection (UEMR) of benign mucosal neoplasms located in the pyloric ring.

Case Summary: This case series describes 4 patients with 4 mucosal neoplasms located in the pyloric ring. The diameter of each neoplasm was less than 15 mm. We performed UEMR for the lesions. Water immersion enabled slight floating of the lesions, resulting in easy identification. We achieved en bloc resection with a snare and electrosurgical unit. All procedure were performed within 3 min without adverse events. Pathologic examination showed low-grade dysplasia with clear resection margins in one case and hyperplastic polyps in three cases.

Conclusion: UEMR can be an effective and safe treatment method for neoplasms in the gastric pyloric ring.
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http://dx.doi.org/10.12998/wjcc.v8.i14.3050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385597PMC
July 2020

Endoscopic and Endosonographic Features of Histologically Proven Gastric Ectopic Pancreas by Endoscopic Resection.

Korean J Gastroenterol 2020 07;76(1):9-16

Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.

Backgrounds/aims: Distinguishing gastric ectopic pancreas (GEP) from malignant tumors is relatively difficult. This study evaluated the endosonography findings of pathologically proven GEP.

Methods: Thirty-one patients diagnosed with GEP based on a histopathological analysis from January 2004 to July 2018 were enrolled in this study. All patients underwent EUS and an endoscopic resection.

Results: Seventeen patients were female, and the median age was 41.1 years (range, 14-74). The lesions were localized most commonly in the antrum. The mean size of the GEP was 10.6 mm (range, 7-15). Superficial type lesions, lesions with heterogeneous echogenicity, mixed pattern lesions, and lesions with indistinct borders were commonly observed on EUS. Calcification, anechoic duct-like structures, and thickening of the muscularis propria were observed in some patients. Endoscopic mucosal resection (41.9%) and endoscopic submucosal dissection (58.1%) were performed. The mean procedure time was 22.5 minutes. Complete resection was achieved for 71% of patients. No statistically significant results between the endosonography findings and complete resection rates were obtained. The mean follow-up esophagogastroduodenoscopy duration was 4.5 months. None of the patients presented with residual lesions on subsequent endoscopy.

Conclusions: EUS can help identify the features of GEP. Careful observations of the EUS findings can avoid unnecessary removal of GEP.
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http://dx.doi.org/10.4166/kjg.2020.76.1.9DOI Listing
July 2020

Association between Charlson comorbidity index and complications of endoscopic resection of gastric neoplasms in elderly patients.

BMC Gastroenterol 2020 Jul 9;20(1):213. Epub 2020 Jul 9.

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chonnam National Medical School, Gwangju, South Korea.

Background: Although endoscopic resection is safe and effective for gastric epithelial neoplasms, information is limited on its efficacy and safety in extremely elderly patients who have various comorbidities. Further, the relationship between comorbidities and complications of endoscopic resection is not well established. Therefore, we aimed to evaluate the efficacy and safety of endoscopic resection of gastric epithelial neoplasms in extremely elderly patients.

Methods: From October 2008 to December 2017, 4475 consecutive patients underwent endoscopic resection of gastric epithelial neoplasms. Among them, 242 were 75 years or older. We assessed Charlson comorbidity index (CCI) scores, procedural outcomes, and procedure- and sedation-related complications related to endoscopic resection.

Results: Mean patient age was 78.7 ± 3.2 years. Of the 242 patients, 124 (51.2%) had low-grade dysplasia and 112 (46.3%) had adenocarcinoma. The most common comorbidity was hypertension (55.4%), followed by diabetes (23.1%). The mean CCI score was 1.67 ± 1.43. Sixty patients (24.8%) had a CCI score ≥ 3. During the procedure, 10 (4.1%) patients had desaturation that recovered by flumazenil use with mask (n = 2) or Ambu bag (n = 3) ventilation. During subsequent admission, atelectasis or pneumonia occurred in 45 (18.6%) patients, post-procedural bleeding in 12 (5.0%), and perforation in 3 (1.2%). Respiratory complications were more common in patients with a CCI score ≥ 3 (20/60, 33.3%) than in those with a CCI score < 3 (25/182, 13.7%, P = 0.002).

Conclusions: CCI score is related to respiratory complications of endoscopic resection in extremely elderly patients. Endoscopic resection must be performed cautiously, particularly in elderly patients with a high CCI score, to prevent respiratory complications.
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http://dx.doi.org/10.1186/s12876-020-01360-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346434PMC
July 2020

Correction to: A rare case of pericarditis and pleural empyema secondary to transdiaphragmatic extension of pyogenic liver abscess.

BMC Infect Dis 2020 Jul 8;20(1):483. Epub 2020 Jul 8.

Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea.

An amendment to this paper has been published and can be accessed via the original article.
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http://dx.doi.org/10.1186/s12879-020-05232-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7346422PMC
July 2020

ERK Regulates NeuroD1-mediated Neurite Outgrowth via Proteasomal Degradation.

Exp Neurobiol 2020 Jun;29(3):189-206

Department of Anatomy, Ajou University School of Medicine, Suwon 16499, Korea.

Neurogenic differentiation 1 (NeuroD1) is a class B basic helix-loop-helix (bHLH) transcription factor and regulates differentiation and survival of neuronal and endocrine cells by means of several protein kinases, including extracellular signal-regulated kinase (ERK). However, the effect of phosphorylation on the functions of NeuroD1 by ERK has sparked controversy based on context-dependent differences across diverse species and cell types. Here, we evidenced that ERK-dependent phosphorylation controlled the stability of NeuroD1 and consequently, regulated proneural activity in neuronal cells. A null mutation at the ERK-dependent phosphorylation site, S274A, increased the half-life of NeuroD1 by blocking its ubiquitin-dependent proteasomal degradation. The S274A mutation did not interfere with either the nuclear translocation of NeuroD1 or its heterodimerization with E47, its ubiquitous partner and class A bHLH transcription factor. However, the S274A mutant increased transactivation of the E-box-mediated gene and neurite outgrowth in F11 neuroblastoma cells, compared to the wild-type NeuroD1. Transcriptome and Gene Ontology enrichment analyses indicated that genes involved in axonogenesis and dendrite development were downregulated in NeuroD1 knockout (KO) mice. Overexpression of the S274A mutant salvaged neurite outgrowth in NeuroD1-deficient mice, whereas neurite outgrowth was minimal with S274D, a phosphomimicking mutant. Our data indicated that a longer protein half-life enhanced the overall activity of NeuroD1 in stimulating downstream genes and neuronal differentiation. We propose that blocking ubiquitin-dependent proteasomal degradation may serve as a strategy to promote neuronal activity by stimulating the expression of neuron-specific genes in differentiating neurons.
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http://dx.doi.org/10.5607/en20021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344372PMC
June 2020

Cryopreserved Human Oocytes and Cord Blood Cells Can Produce Somatic Cell Nuclear Transfer-Derived Pluripotent Stem Cells with a Homozygous HLA Type.

Stem Cell Reports 2020 07 4;15(1):171-184. Epub 2020 Jun 4.

CHA Advanced Research Institute, CHA University, Seongnam, Gyunggi-do 13488, Korea; Department of Biomedical Science, CHA University, Seongnam, Gyunggi-do 13488, Korea. Electronic address:

Human pluripotent stem cells (PSCs) through somatic cell nuclear transfer (SCNT) may be an important source for regenerative medicine. The low derivation efficiency of stem cells and the accessibility of human oocytes are the main obstacles to their application. We previously reported that the efficiency of SCNT was increased by overexpression of H3K9me3 demethylase. Here, we applied a modified derivation method to the PSC line and first obtained human SCNT-PSC lines derived from both donated cryopreserved oocytes and cord blood cells with a homozygous human leukocyte antigen (HLA) type. The SCNT-PSCs have very similar characteristics with embryonic stem cells (ESCs) and additionally have shown immunocompatibility in an in vitro and in vivo humanized mouse with a matching HLA type. Our study demonstrates that SCNT technology using donated cryopreserved oocytes and cord blood cells with a known HLA type provides a promising method for establishing a human HLA-matched SCNT-PSC bank for regenerative medicine.
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http://dx.doi.org/10.1016/j.stemcr.2020.05.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7363744PMC
July 2020

Messenger RNA/polymeric carrier nanoparticles for delivery of heme oxygenase-1 gene in the post-ischemic brain.

Biomater Sci 2020 Jun 29;8(11):3063-3071. Epub 2020 Apr 29.

Department of Bioengineering, College of Engineering, Hanyang University, Seoul, 04763, Korea.

Ischemic stroke is a cerebrovascular disease caused by narrowed cerebral arteries. Thrombolytic agents such as tissue-plasminogen activators have been used for recanalization of the blood supply into the ischemic region. However, ischemia-reperfusion damage continues to increase the infarction volume. In this study, heme oxygenase-1 (HO1)-mRNA was delivered into the brain, using a non-viral carrier. Various non-viral carriers such as polyethylenimine (25 kDa, PEI25k), lipofectamine, dexamethasone-conjugated PEI2k (Dexa-PEI2k), deoxycholic acid-conjugated PEI2k (DA-PEI2k), and R3V6 peptides were evaluated as carriers of mRNA into the brain. Gene delivery assays showed that DA-PEI2k and lipofectamine had a higher mRNA delivery efficiency than the other carriers in Neuro2A cells in vitro and a rat brain in vivo. Cytotoxicity assays showed that lipofectamine had higher toxicity than DA-PEI2k. Therefore, DA-PEI2k was used for delivery of HO1-mRNA. Unlike plasmid DNA (pDNA), mRNA is expressed in the cytosol without nuclear translocation. This suggests that mRNA may have higher gene expression than pDNA, since the nuclear location of pDNA is an inefficient step. Indeed, in in vitro transfection assays, HO1-mRNA/DA-PEI2k had higher gene expression than HO1-pDNA/DA-PEI2k without induction of a pro-inflammatory cytokine. The therapeutic effects of HO1-mRNA delivery using DA-PEI2k were evaluated in the middle cerebral artery occlusion animal model after local injection. HO1-mRNA delivery had higher gene expression than HO1-pDNA delivery 24 h after the local injection. In addition, HO1-mRNA delivery reduced the infarct size more efficiently than HO1-pDNA delivery. The results suggest that the delivery of mRNA using DA-PEI2k may be useful for gene therapy of ischemic stroke.
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http://dx.doi.org/10.1039/d0bm00076kDOI Listing
June 2020

Experience of Endoscopists in Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy Patients.

Authors:
Chang-Hwan Park

Clin Endosc 2020 Jan 30;53(1):7-8. Epub 2020 Jan 30.

Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.

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http://dx.doi.org/10.5946/ce.2020.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7003008PMC
January 2020

[Influencing Factors on Lactulose Breath Test Results].

Korean J Gastroenterol 2020 01;75(1):23-28

Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.

Background/aims: This study aimed to identify the demographic and clinical factors associated with positive breath-test results and to assess the relationship between hydrogen and methane production in patients with suspected irritable bowel syndrome (IBS).

Methods: The demographic and clinical factors of 268 patients with suspected IBS, who had undergone a lactulose breath test, were analyzed.

Results: Of 268 patients included in this study, 143 (53.4%) were females. The median age and BMI of the patients was 58.0 years (range, 18.0-80.0 years) and 22.5 kg/m (range, 14.4-34.3 kg/m), respectively. A weak positive correlation was observed between the BMI and baseline hydrogen level (rho=0.134, p=0.031). Women were significantly more likely to show a ≥20 ppm increase in hydrogen within 90 min (early hydrogen increase, p=0.049), a ≥10 ppm increase in methane within 90 min (early methane increase, p=0.001), and a ≥10 ppm increase in methane between 90 min and 180 min (late methane increase, p=0.002) compared to men. The baseline hydrogen level was related to the baseline methane level (rho=0.592, p<0.001) and the maximal hydrogen level within 90 min was related to maximal methane level within 90 min (rho=0.721, p<0.001). Patients with an early hydrogen increase (43.8%) were more likely to show a positive result for an early methane increase compared to patients without an early increase in hydrogen (0%, p<0.001).

Conclusions: Women were associated with high rates of positive lactulose breath-test results. In addition, methane production was correlated with hydrogen production.
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http://dx.doi.org/10.4166/kjg.2020.75.1.23DOI Listing
January 2020

Pneumocystis pneumonia after use of corticosteroids in a man with severe alcoholic hepatitis: A case report.

Medicine (Baltimore) 2020 Jan;99(2):e18696

Department of Gastroenterology and Hepatology.

Rationale: Severe alcoholic hepatitis (AH) has a very high mortality rate. Current guidelines recommend oral corticosteroids as first-line agents in individuals with severe AH to reduce short-term mortality. However, systemic corticosteroids have serious adverse effects. In individuals with AH, infection, which is one of the complications of steroid use, can result in serious outcomes, such as acute-on-chronic liver failure. Pneumocystis pneumonia (PCP) is a life-threatening opportunistic infection which may occur when high-dose corticosteroids are prescribed for more than 1 month. Therefore, when high-dose corticosteroids are used, providing PCP prophylaxis is warranted. Although trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for the prophylaxis of PCP, its hepatotoxicity limits its use in patients with severe AH who are on high-dose corticosteroids. Moreover, there is a lack of consensus on which drugs should be used for PCP prophylaxis in individuals with severe AH who are on glucocorticoid treatment. Herein, we report a case of a 43-year-old male with fatal PCP that occurred after the use of corticosteroids for severe AH.

Patient Concerns: A 43-year-old alcoholic man presented with a hematoma on his right leg. His liver function was poor, and he was he was diagnosed with severe AH and treated with oral corticosteroids for 26 days. After glucocorticoid treatment, he developed a productive cough.

Diagnoses: A sputum PCR test was positive for Pneumocystis jirovecii.

Interventions: He was initially treated with TMP-SMX and required artificial ventilation.

Outcomes: He developed disseminated intravascular coagulation and multi-organ failure, and died 10 days after starting TMP-SMX.

Lessons: To date, prevention of PCP in individuals with severe AH who are on corticosteroids has been overlooked. This case illustrates the need for prophylaxis of PCP in individuals with severe AH taking corticosteroids.
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http://dx.doi.org/10.1097/MD.0000000000018696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6959895PMC
January 2020

Defective neurogenesis and schizophrenia-like behavior in PARP-1-deficient mice.

Cell Death Dis 2019 12 9;10(12):943. Epub 2019 Dec 9.

Department of Molecular Biology, Sejong University, Seoul, 05006, Republic of Korea.

In the current study we present evidence suggesting that PARP-1 regulates neurogenesis and its deficiency may result in schizophrenia-like behavioral deficits in mice. PARP-1 knockout neural stem cells exhibited a marked upregulation of embryonic stem cell phosphatase that can suppress the proliferative signaling of PI3K-Akt and ERK. The suppressed activity of Akt and ERK in the absence of PARP-1 results in the elevation of FOXO1 activity and its downstream target genes p21 and p27, leading to the inhibition of neural stem cell proliferation. Moreover, expression of neurogenic factors and neuronal differentiation were decreased in the PARP-1 knockout neural stem cells whereas glial differentiation was increased. In accordance with the in vitro data, PARP-1 knockout mice exhibited reduced brain weight with enlarged ventricle as well as decreased adult neurogenesis in the hippocampus. Interestingly, PARP-1 knockout mice exhibited schizophrenia-like symptoms such as anxiety, depression, social interaction deficits, cognitive impairments, and prepulse inhibition deficits. Taken together, our results suggest that PARP-1 regulates neurogenesis during development and in adult and its absence may lead to the schizophrenia-like behavioral abnormality in mice.
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http://dx.doi.org/10.1038/s41419-019-2174-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6901579PMC
December 2019

Main duct and mixed type intraductal papillary mucinous neoplasms without enhancing mural nodules: Duct diameter of less than 10 mm and segmental dilatation of main pancreatic duct are findings support surveillance rather than immediate surgery.

Pancreatology 2019 Dec 24;19(8):1054-1060. Epub 2019 Sep 24.

Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea. Electronic address:

Objective: The guidelines for pancreatic intraductal papillary mucinous neoplasms (IPMNs) recommend surgical resection of all main-duct (MD) and mixed-type IPMNs in surgically fit patients. We conducted this study to identify the rates of high-grade dysplasia (HGD) and invasive carcinoma according to the morphological features of the main pancreatic duct (MPD) in patients with MD and mixed IPMN.

Methods: We performed a retrospective study of 259 patients with histologically proven MD and mixed-type IPMNs who underwent surgery at six academic institutions.

Results: The rate of HGD and invasive carcinoma was 11.1% (24/216) in patients without enhancing mural nodules (MNs) and 69.8% (30/43) in patients with MNs. Multivariate analysis showed that MPD diameter of ≥10 mm [odds ratio (OR), 2.5; 95% confidence interval (CI), 1.155-5.505; P = 0.02], diffuse MPD dilatation (OR, 3.2; 95% CI, 1.152-8.998; P = 0.02), and presence of enhancing MNs in MPD (OR, 9.6; 95% CI, 3.928-23.833, P < 0.0001) were significant predictors of HGD and invasive carcinoma. Of the 216 patients without enhancing MNs, 79 patients (36.6%) having both segmental MPD dilatation and MPD diameter of <10 mm showed significantly lower rates of HGD and invasive carcinoma (3/79, 3.8%) than patients having both diffuse MPD dilatation and MPD diameter ≥10 mm (9/36, 25%, P = 0.001).

Conclusions: MD and mixed-type IPMNs having segmental MPD dilatation with MPD dilation <10 mm and no enhancing MNs on imaging showed a significantly lower rate of HGD and invasive carcinoma, and watchful follow-up instead of immediate surgical resection might be possible in these patients.
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http://dx.doi.org/10.1016/j.pan.2019.09.010DOI Listing
December 2019

Updates on the Sedation for Gastrointestinal Endoscopy.

Clin Endosc 2019 Sep 30;52(5):451-457. Epub 2019 Sep 30.

Department of Internal Medicine, Yeongnam University College of Medicine, Daegu, Korea.

Sedation, defined as the depressed level of consciousness, induced by drug administration, is widely used for gastrointestinal endoscopy to relieve a patient's anxiety and discomfort. In addition, successful procedure is anticipated with control of unintended movements. Endoscopic sedation, however, cannot be free from the risk of serious adverse events, e.g., cardiopulmonary compromise. Therefore, principles on personnel, facility and equipment, as well as performance itself, should be followed to prevent unfavorable incidents. In this article, sedation guidelines for the Accreditation of Qualified Endoscopy Units, issued by the Korean Society of Gastrointestinal Endoscopy, are presented.
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http://dx.doi.org/10.5946/ce.2019.172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785422PMC
September 2019

X-rays and scans can fail to differentiate hip pathology from lumbar spinal stenosis: Two case reports.

Surg Neurol Int 2019 23;10:165. Epub 2019 Aug 23.

Departments of Neurosurgery Nanoori Hospital, Seoul, Republic of Korea.

Background: Occasionally, hip pathologies may present alone or combined with lumbar spine pathology, especially lumbar stenosis. Although the history and clinical examination may help differentiate between the two, hip X-rays alone without accompanying magnetic resonance imaging (MRI) studies may prove unreliable.

Case Descriptions: Case 1 - A 72-year-old male presented with the sudden onset of severe back and left posterior thigh pain. Straight leg raising test was positive at 70° (right) and 60° (left), and he had left lower extremity numbness and weakness. The lumbar MRI showed L5-S1 spinal stenosis. Although X-rays of both hips were negative, the MRI showed bilateral femoral neck fractures. He underwent screw fixation of the hip fractures and later underwent endoscopic decompression of the spinal stenosis. Case 2 - A 35-year-old male presented with low backache and right hip pain of 1 month's duration. The neurological examination was normal, except for positive straight leg raising bilaterally at 60°. The spine MRI was normal. However, despite negative X-ray of both hips, the hip MRI revealed avascular necrosis (AVN) of both femoral heads requiring subsequent orthopedic management.

Conclusion: Hip pathology may mimic lumbar spinal stenosis. In the two cases presented, plain X-rays failed to document hip fractures (case 1) and AVN (case 2), respectively, both of which were later diagnosed on MRI studies.
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http://dx.doi.org/10.25259/SNI_173_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6763674PMC
August 2019

Dopamine neuron induction and the neuroprotective effects of thyroid hormone derivatives.

Sci Rep 2019 09 20;9(1):13659. Epub 2019 Sep 20.

Hanyang Biomedical Research Institute, Hanyang University, Seoul, 04763, Korea.

Parkinson's disease (PD) is a neurodegenerative disease characterized by progressive movement disturbances caused by the selective loss of dopamine (DA) neurons in the substantia nigra. Despite the identification of the causal mechanisms underlying the pathogenesis of PD, effective treatments remain elusive. In this study, we observed that a low level of fetal bovine serum (FBS) effectively induced DA neurons in rat neural precursor cells (NPCs) by enhancing nuclear receptor-related 1 protein (NURR1) expression. Among the various components of FBS, the thyroid hormones triiodothyronine (T3) and thyroxine (T4) were identified as key factors for the induction of DA neurons. Since an overdose of thyroid hormones can cause hyperthyroidism, we synthesized several thyroid hormone derivatives that can partially activate thyroid hormone receptors and induce the complete differentiation of NPCs into DA neurons. Two derivatives (#3 and #9) showed positive effects on the induction and maturation of DA neurons without showing significant affinity for the thyroid hormone receptor. They also effectively protected and restored DA neurons from neurotoxic insults. Taken together, these observations demonstrate that thyroid hormone derivatives can strongly induce DA neuron differentiation while avoiding excessive thyroid stimulation and might therefore be useful candidates for PD treatment.
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http://dx.doi.org/10.1038/s41598-019-49876-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754465PMC
September 2019

A prospective, randomized, multicenter clinical trial comparing 25-gauge and 20-gauge biopsy needles for endoscopic ultrasound-guided sampling of solid pancreatic lesions.

Surg Endosc 2020 Mar 17;34(3):1310-1317. Epub 2019 Jun 17.

Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Republic of Korea.

Background: Various core biopsy needles have previously been developed for endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB). However, the properties of needle gauge in the diagnostic outcomes of solid pancreatic lesions remain unknown. This trial compared the procurement rates of histologic cores from solid pancreatic lesions with EUS-FNB using 20- and 25-gauge (G) FNB needles.

Methods: In a prospective randomized multicenter clinical trial, patients with solid pancreatic lesions underwent EUS-FNB with either a 20-gauge or a 25-gauge FNB needle. The rates of histologic core procurement, overall diagnostic accuracy, and adverse events were compared between the two groups (20-gauge or 25-gauge FNB needle).

Results: In total, 88 patients (48 men, 40 women, mean age 65.7 years) were enrolled. No significant differences were found in the demographic characteristics between the two groups (20-gauge or 25-gauge FNB needle). The procurement rate of histologic cores in the 20-guage FNB needle group (41/45, 91.1%) was significantly higher than that in the 25-guage FNB needle group (32/43, 74.4%, P = 0.037). However, no significant differences were found in the overall diagnostic accuracy between 20-guage FNB needle (40/45, 88.9%) and 25-guage FNB needle (34/43, 79.1%, P = 0.208). No procedure-related adverse events were observed in either group.

Conclusions: Although both FNB needles provided high overall diagnostic accuracy, the reliability of the 20-guage FNB needle is better than the 25-guage FNB needle when retrieving samples for histological analysis.
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http://dx.doi.org/10.1007/s00464-019-06903-xDOI Listing
March 2020

Association Between Gastric Emptying Time and Incidence of Cardiovascular Diseases in Subjects With Diabetes.

J Neurogastroenterol Motil 2019 Jul;25(3):387-393

Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.

Background/aims: Delayed gastric emptying (GE) is associated with high morbidity and mortality in subjects with diabetes. The aim of this study is to investigate associations between GE time and the major cardiovascular events (coronary heart diseases and ischemic stroke) in diabetic subjects with upper gastrointestinal (UGI) symptoms.

Methods: Among 259 subjects with chronic UGI symptoms who underwent gastric emptying study (GES) over 13 years, 122 diabetic subjects without gastric surgery and/or rapid GE were enrolled in this study. We also gathered data about baseline demographics, clinical characteristics, estimated GE half-time (GE T) and incidence of cardiovascular events following GES.

Results: The mean age of subjects was 64.0 ± 17.4 years. There were 86 women and 104 subjects with type 2 diabetes. There were 52 (42.6%) subjects with normal GE, 50 (41.0.%) subjects with mild delayed GE, and 20 (16.4%) subjects with marked delayed GE. During follow-up (median, 207 weeks), cardiovascular events occurred in 7 (13.5%) subjects with normal GE, 4 (8.0%) subjects with mild delayed GE and 7 (35.0%) subjects with marked GE ( P = 0.015). Univariate analysis showed that GE T was significantly associated with incidence of cardiovascular events (crude OR, 1.74; 95% CI, 1.12-2.69; P = 0.014). In a multivariate model, association between GE T and incidence of cardiovascular events remained statistically significant after adjustment for baseline characteristics and comorbidities (adjusted OR, 1.94; 95% CI, 1.21-3.12; P = 0.006).

Conclusion: A delay of GE was associated with an increased incidence of cardiovascular events in diabetic subjects with chronic UGI symptoms.
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http://dx.doi.org/10.5056/jnm19037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657932PMC
July 2019

Preparation and Characterization of the Sputtered TiAlN Coatings Using a Ti-Al Alloy Metal Target.

J Nanosci Nanotechnol 2019 Oct;19(10):6493-6498

Department of Advanced Materials and Chemical Engineering, Daegu Catholic University, Gyeongbuk 38430, Korea.

Titanium aluminium nitride (TiAlN) ternary coatings were deposited on glass substrates by means of reactive magnetron sputtering technique, using a Ti-Al alloy metal target (TiA). The depositions were performed at various N2 and Ar flux ratios of N₂/(Ar + N₂) ═ 33, 50, 67, 83%. The structure, morphology, chemical composition and mechanical properties were investigated by X-ray diffraction (XRD), field emission scanning electron microscope (FE-SEM), energy dispersive X-ray spectroscopy (EDS), and nano indenter (MTS System), respectively. The orientation of coatings depends on the flux ratios of N₂/(Ar + N₂) and substrate temperature. The coatings deposited with N₂/(Ar + N₂) ratios of 33, 50 at.% consists of pyramid-like column grains separated by porous and voids, which can be attributed to cubic-TiN (220) preferred orientation. The coatings deposited with N₂/(Ar + N₂) greater than 67% exhibits the phase of hexagonal-AlN and cubic-TiN. The surface of coatings becomes more compact and smoother with the N₂/(Ar + N₂) ratios increase. The coatings deposited with N₂/(Ar+N₂) ratio of 83% shows the largest hardness of 21.5 GPa, which is attributed to the preferred (200) orientation. However, this hardness increases significantly with increasing substrate temperature. The coatings deposited at more than 100 °C exhibited the (111) and/or (200) orientation. The amounts of grains grown along the (111) and (200) orientations play a significant role on the mechanical performance of TiAlN coatings. Four independent mechanisms, such as TiAlN stoichiometry and lattice parameter, the (111) preferred growth orientation, and the density increases (elimination of void), were found to contribute to the enhancement of TiAlN mechanical performance.
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http://dx.doi.org/10.1166/jnn.2019.17059DOI Listing
October 2019

Hybrid Nanofiber Scaffold-Based Direct Conversion of Neural Precursor Cells/Dopamine Neurons.

Int J Stem Cells 2019 Jul;12(2):340-346

Graduate School of Biomedical Science & Engineering, Hanyang University, Seoul, Korea.

The concept of cellular reprogramming was developed to generate induced neural precursor cells (iNPCs)/dopaminergic (iDA) neurons using diverse approaches. Here, we investigated the effects of various nanoscale scaffolds (fiber, dot, and line) on iNPC/iDA differentiation by direct reprogramming. The generation and maturation of iDA neurons (microtubule-associated protein 2-positive and tyrosine hydroxylase-positive) and iNPCs (NESTIN-positive and SOX2-positive) increased on fiber and dot scaffolds as compared to that of the flat (control) scaffold. This study demonstrates that nanotopographical environments are suitable for direct differentiation methods and may improve the differentiation efficiency.
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http://dx.doi.org/10.15283/ijsc18123DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657951PMC
July 2019

Characteristics and Outcomes of Extreme Elderly Patients With Hepatocellular Carcinoma in South Korea.

In Vivo 2019 Jan-Feb;33(1):145-154

Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.

Background/aim: The number of elderly patients diagnosed with hepatocellular carcinoma (HCC) has been increasing. But there is no proper management based on age stratification in elderly patients. Therefore, we evaluated the clinical characteristics and outcomes of elderly HCC patients more than 75 years old in South Korea.

Patients And Methods: Five hundred and fifty elderly patients with HCC were enrolled and divided into the oldest-old (age ≥85 years), middle-old (age between 80 and 85 years), and young-old groups (age between 75 and 80 years).

Results: Fifty-one, 153, and 346 patients were included in the oldest-old (mean age: 87 years), middle-old (mean age: 82 years), and young-old groups (mean age: 77 years), respectively. There was a significantly lower rate of alcohol-related and hepatitis B virus-related diseases in the oldest-old group than in the other groups, whereas there was no significant difference in other characteristics. With increasing age, conservative treatment was predominantly performed. Transarterial chemoembolization was the main modality of active treatment in all groups. In multivariate analysis, the performance score, model for end-stage liver disease score, modified Union for International Cancer Control staging, Barcelona Clinic Liver Cancer staging, presence of portal vein tumor thrombosis, ruptured HCC, and active treatment were risk factors of overall survival.

Conclusion: When the therapeutic approach is used in elderly patients with HCC, the patient's performance status, liver function, and stage of cancer should be considered, and its use should not be restricted to those of advanced age.
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http://dx.doi.org/10.21873/invivo.11451DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364080PMC
April 2019

Lower expression of endogenous intestinal alkaline phosphatase may predict worse prognosis in patients with Crohn's disease.

BMC Gastroenterol 2018 Dec 17;18(1):188. Epub 2018 Dec 17.

Division of Gastroenterology and Hepatology, Chonnam National University Medical School, Gwangju, South Korea.

Backgrounds: Intestinal alkaline phosphatase (IAP) plays important role in gut homeostasis. We aimed to evaluate the expression of endogenous IAP and to assess the clinical course according to the expression of endogenous IAP in patients with Crohn's disease (CD).

Methods: A total of 32 consecutive patients (14 males) with CD were included in the study. We measured the level of endogenous iAP in inflamed and noninflamed colonic mucosa. To verify the inflammation status, we measured the level of mRNA for IL-6, TNF-α, and TLR-4. We monitored the clinical courses of patients during follow-up after acquisition of biopsy specimens.

Results: Median age of patients was 22.5 years (range, 15-49). Median CD activity index (CDAI, range) was 93.7 (22.8~ 154.9). There were colonic involvements in all patients and perianal involvement in 43.8% patients. The mRNA levels of IL-6 (p = 0.005) and TLR-4 (p = 0.013) in inflamed mucosa were significantly higher than those in non-inflamed mucosa. However, there was no difference of expression of TNF-α mRNA (p = 0.345). During a 14-month follow-up (range, 9 months-54 months), there were 19 patients with clinical recurrences. There were 9 patients (9/19, 47.4%) with IAP expression ratio (inflamed to non-inflamed) ≤ 1.0 in patients with clinical recurrence while there was one patient (1/13, 7.7%) with IAP ratio ≤ 1.0 in patients without clinical recurrence (p = 0.024).

Conclusion: Lower expression of IAP in inflamed mucosa compared to non-inflamed mucosa may be associated with clinical recurrence in patients with CD.
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http://dx.doi.org/10.1186/s12876-018-0904-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296121PMC
December 2018

Cell Surface Antigen Display for Neuronal Differentiation-Specific Tracking.

Biomol Ther (Seoul) 2019 01;27(1):78-84

Graduate School of Biomedical Science and Engineering, Hanyang University, Seoul 04763, Republic of Korea.

Cell therapeutic agents for treating degenerative brain diseases using neural stem cells are actively being developed. However, few systems have been developed to monitor in real time whether the transplanted neural stem cells are actually differentiated into neurons. Therefore, it is necessary to develop a technology capable of specifically monitoring neuronal differentiation . In this study, we established a system that expresses cell membrane-targeting red fluorescent protein under control of the promoter in order to specifically monitor differentiation from neural stem cells into neurons. In order to overcome the weak expression level of the tissue-specific promoter system, the partial 5' UTR sequence of was added for efficient expression of the cell surface-specific antigen. This system was able to track functional neuronal differentiation of neural stem cells transplanted , which will help improve stem cell therapies.
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http://dx.doi.org/10.4062/biomolther.2018.110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6319552PMC
January 2019

The effect of cell penetrating peptide-conjugated coactivator-associated arginine methyltransferase 1 (CPP-CARM1) on the cloned mouse embryonic development.

Sci Rep 2018 11 13;8(1):16721. Epub 2018 Nov 13.

Department of Biomedical Science, CHA University, Seongnam, 13488, Korea.

Abnormalities in gene expression that negatively affect embryonic development are frequently observed in cloned embryos generated by somatic cell nuclear transfer (SCNT). In the present study, we successfully produced a cell-penetrating peptide (CPP)-conjugated with coactivator-associated arginine methyltransferase 1 (CARM1) protein from mammalian cells and confirmed introduction into donor somatic cells and cloned 8-cell embryos within 3 hours after addition to culture medium. In addition, H3R17 dimethylation and embryonic development up to the blastocyst stage were increased in the group treated with exogenous CPP-CARM1 protein compared with the untreated group (control). Interestingly, the number of total cells and trophectoderm in blastocysts as well as implantation rate were significantly increased in the CPP-CARM1 protein-treated group. However, the cell number of inner cell mass (ICM) was not changed compared with the control group; similarly, expression of pluripotency-related genes Oct4 and Nanog (ICM markers) was not significantly different between groups. On the other hand, expression of the implantation-related gene Cdx2 (trophectoderm marker) was transiently increased after treatment with CPP-CARM1 protein. On the basis of these results, we conclude that supplementation with exogenous CPP-CARM1 protein improves embryonic development of cloned embryos through regulation of histone methylation and gene expression. In addition, our results suggest that CPP-CARM1 protein may be a useful tool for strengthening implantation of mammalian embryos.
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http://dx.doi.org/10.1038/s41598-018-35077-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6233168PMC
November 2018

Risk Factors and On-site Rescue Treatments for Endoscopic Variceal Ligation Failure.

Korean J Gastroenterol 2018 Oct;72(4):188-196

Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.

Background/aims: The success rate of endoscopic variceal ligation (EVL) is about 85-94%. There is only a few studies attempting to determine the cause of EVL failure, and to date, on-site rescue treatments remains unestablished. This study aimed to elucidate the risk factors for EVL failure and the effectiveness of on-site rescue treatment.

Methods: Data of 454 patients who underwent emergency EVL at Chonnam National University Hospital were retrospectively analyzed. Enrolled patients were divided into two groups: the EVL success and EVL failure groups. EVL failures were defined as inability to ligate the varices due to poor endoscopic visual field, or failure of hemostasis after band ligation for the culprit lesion.

Results: Forty-seven patients experienced EVL failure. In the multivariate analysis, male patients, initial hypovolemic shock, active bleeding on endoscopy, and history of previous EVL were independent risk factors for EVL failure. During endoscopic procedure, we came across the common causes of EVL failure, including unsuctioned varix due to previous EVL-induced scars followed by insufficient ligation of the stigmata and inability to ligate the varix due to poor endoscopic visual field. Endoscopic variceal obturation using N-butyl-2-cyanoacrylate (48.9%) was the most commonly used on-site rescue treatment method, followed by insertion of Sangstaken Blakemore tube (14.9%), and EVL retrial (12.8%). The rescue treatments successfully achieved hemostasis in 91.7% of those in the EVL failure group.

Conclusions: The risk factors of EVL failure should be considered before performing EVL, and in case of such scenario, on-site rescue treatment is needed.
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http://dx.doi.org/10.4166/kjg.2018.72.4.188DOI Listing
October 2018

Symptomatic Tuberculous Ligamentum Flavum Cyst Treated by Full Endoscopic Resection: Review with Technical Notes.

World Neurosurg 2019 Feb 1;122:112-115. Epub 2018 Nov 1.

Department of Neurosurgery Nanoori Hospital, Gangnam, Seoul, Republic of Korea.

Background: Tuberculosis (TB) of the posterior spinal element is an uncommon condition. In a developed country its diagnosis is becoming difficult due to low incidence.

Case Description: A 60-year-old lady presented with low back pain and right leg pain for 6 months. On examination there was tenderness over L4 and L5, a positive straight leg raise test at 70 degrees on the right side and free on the left, and sensory involvement on the right L5 dermatome. Initial magnetic resonance imaging (MRI) showed an L4-5 ligamentum flavum cyst, high signal intensity in the right pedicle and facet joint. It was considered to be a degenerative spinal disorder. Later MRI showed increased size of the cyst, and computed tomography revealed erosion of the right pedicle of the L5 vertebrae, which raised the suspicion of the tubercular pathology. Initially the patient was managed for a degenerative spinal disorder. Later, when tubercular pathology was suspected, she underwent full endoscopic uniportal stenosis decompression and excision biopsy of the cyst. The histology of the cyst revealed chronic granulomatous inflammation with central necrosis. The diagnosis of a TB cyst was confirmed, and antitubercular therapy was started.

Conclusion: TB of the posterior elements of the spine is a diagnostic challenge in developed parts of the world. We describe the first likely case of tubercular ligamentum flavum cyst, which was managed by a full endoscopic uniportal approach.
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http://dx.doi.org/10.1016/j.wneu.2018.10.141DOI Listing
February 2019

Isolation and identification of α-glucosidase inhibitory constituents from the seeds of Vigna nakashimae: Enzyme kinetic study with active phytochemical.

Food Chem 2018 Nov 15;266:483-489. Epub 2018 Jun 15.

Division of Research Development and Education, National Institute of Chemical Safety (NICS), Ministry of Environment, Daejeon 34111, Republic of Korea. Electronic address:

The α-glucosidase inhibition effects of the 80% ethanol extracts in the seeds of five Vigna species (V. nakashimae, V. nipponensis, V. umbellate, V. radiate, and V. angularis) were evaluated and their half-maximal inhibitory concentration (IC) values showed considerable differences (p < 0.05) ranging from 7.3 to >900 μg/ml. V. nakashimae exhibited the most potent inhibition with IC value of 7.3 ± 1.1 μg/ml, followed by V. nipponensis (184.0 ± 9.5 μg/ml) and V. umbellata (520.0 ± 8.1 μg/ml). Bioactivity-guided fractionation of V. nakashimae seeds yielded three phenolics by silica gel chromatography and their structures were elucidated as gambiriin D (1), luteoliflavan-7-O-glucopyranoside (2), and catechin-7-O-glucopyranoside (3) using nuclear magnetic resonance (NMR) spectroscopy. In particular, gambiriin D (1) possessed strong inhibition activity with IC of 36.8 ± 2.3 μM through simple reversible slow-binding inhibition (kinetic parameters: k = 0.0048  μMs; K = 48 μM). Furthermore, this compound inhibited recombinant human aldose reductase with IC value of 12.0 ± 0.7 μM. Results suggest that V. nakashimae may be a potent α-glucosidase inhibition for health products.
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http://dx.doi.org/10.1016/j.foodchem.2018.06.039DOI Listing
November 2018

Feasibility of a 20-gauge ProCore needle in EUS-guided subepithelial tumor sampling: a prospective multicenter study.

BMC Gastroenterol 2018 Oct 19;18(1):151. Epub 2018 Oct 19.

Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.

Background: Endoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) may facilitate tissue acquisition for a definitive diagnosis of gastrointestinal subepithelial tumors (SETs). This study aimed to determine the diagnostic yield of EUS-FNB using a novel 20-gauge ProCore needle with a coiled sheath in tissue sampling of gastrointestinal SETs.

Methods: Between July 2016 and February 2017, 39 patients with gastrointestinal SETs were prospectively recruited from six university hospitals in Korea. Hypoechoic SETs ≥2 cm in size and originating from the submucosal and/or muscularis propria layer under EUS were eligible. This study was registered on ClinicalTrials.gov (NCT02884154).

Results: A total of 36 patients were included in the final analyses. EUS-FNB was diagnostic in 88.9% of SETs. Tissue adequacy was judged as optimal in 97.2% of FNB specimens according to on-site visual evaluation by endosonographers, and in 88.9% of specimens according to pathologists. A macroscopically optimal core sample was obtained with two needle passes in 94.4% of cases. Technical failure rate was encountered in two cases (5.6%) after two needle passes. There were two cases (5.6%) of bleeding, which was managed endoscopically.

Conclusions: EUS-FNB using a 20-gauge ProCore needle is a technically feasible and effective modality for histopathologic diagnosis of gastrointestinal SETs, providing adequate core samples with fewer needle passes; ClinicalTrials.gov number, NCT02884154.
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http://dx.doi.org/10.1186/s12876-018-0880-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194594PMC
October 2018