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Background: Sedation, defined as the depressed level of consciousness induced by the administration of drugs, is used widely for gastrointestinal endoscopy to relieve the patient’s anxiety and discomfort. In addition, a successful procedure can be anticipated with the control of unintended movements. Therefore, sedation has become an essential element of gastrointestinal endoscopy.Current Concepts: Sedation is classified into the following four stages according to the level of consciousness: minimal sedation or anxiolysis, moderate sedation or conscious sedation, deep sedation, and general anesthesia. The degree of response to sedation varies from person to person, depending on the age, underlying diseases, alcohol or medication intake, anxiety level, sensitivity to pain, and pharmacogenetic characteristics. In particular, certain situations require special attention not only during preoperative evaluation but also during the procedure and recovery, such as old age, obesity, pregnancy, lactation, and liver cirrhosis. Therefore, the same procedure may require different levels of sedation in different patients, and some patients may even experience changing levels of sedation during a single procedure.Discussion and Conclusion: Although most patients undergoing gastrointestinal endoscopy under sedation recover without any problem, various types of adverse events related to sedation may occur occasionally. In rare cases, serious complications may occur that threaten the patient’s life. Therefore, basic principles governing the facilities and equipment as well as performance of sedation itself should be followed to prevent unfavorable accidents. Moreover, every medical personnel should be familiar with the pharmacological properties of the drugs used for sedation and trained for emergencies.

Purpose: To report a case of combination therapy with interferon β1b (IFN-β1b) and mitomycin-C (MMC) for recurrent ocular surface squamous neoplasia (OSSN).Case summary: A 72-year-old female presented with a white mass at the medial conjunctiva of the right eye. A gelatinous, nodular white lesion was observed near the medial limbus of the right eye. On histological examination, it was diagnosed as squamous cell carcinoma in situ. A white nodule was found at the resection site 1 year after the resection. IFN-β1b (1 mIU/mL) and 0.02% MMC were administered daily with a diagnosis of recurrent OSSN. IFN-β1b was instilled four times a day for 1 month, while MMC was instilled four times a day for 4 weeks. After 1 month of the combination treatment, the lesion disappeared. MMC was stopped, while IFN-β1b was reduced to twice daily instillation, maintained for 1 month, and then stopped. On examination 12 months after discontinuation of the combination treatment, there were no recurrences or drug-related complications.Conclusions: Combination therapy with IFN-β1b and MMC for recurrent OSSN after surgical resection was relatively safe with no major complications.

This study aimed to determine changes in endoscopist-driven sedation practices 5 years after the first nationwide survey in 2014 by the Korean Society of Gastrointestinal Endoscopy (KSGE).A 59-item survey covering current practices was electronically mailed to all members of the KSGE in 2019.In total, 955 (12.8%) out of 7,486 questionnaires were returned. A total of 738 (77.7%) out of 955 respondents attended dedicated sedation education programs. The American Society of Anesthesiologists class was recorded by 464 (51.2%) out of 907 respondents. The recording rate was higher in respondents who completed sedation education (p=0.014) and worked in general or tertiary hospitals (p0.001). Compared to that reported in the previous survey, the reported use of propofol was higher in 2019. The respondents had higher satisfaction scores for propofol-based sedation compared with midazolam monotherapy (p0.001). The rates of oxygen supplementation (p0.001) and oxygen saturation level monitoring (p0.001) during sedative endoscopy were higher in 2019 than in the previous survey. A total of 876 (98.4%) out of 890 respondents reported a separate recovery bay, and 615 (70.5%) out of 872 respondents reported that personnel were assigned solely to the recovery bay.Endoscopist-driven sedation and monitoring practices in 2019 were significantly different than those in 2014. The respondents favored propofol-based sedation and utilized oxygen supplementation and monitoring of O

Efficient bowel preparation is essential for preventing colorectal cancer by improving endoscopic adenoma detection. Tablet for bowel preparation containing sulfate salts, OSTs (oral sulfate tablets), has been developed and it is gaining more popularity. However, its efficacy compared to standard preparation agent, PEG-AA (polyethylene glycol), has not been well discovered. We assessed the efficacy of PEG and OSTs using a real-time clinical data warehouse (CDW) model.We performed a propensity score-matched (PSM) analysis of consecutive adult patients undergoing colonoscopy who received PEG-AA or OSTs prior to colonoscopy at a tertiary academic hospital. The endoscopic records of 992 adult patients were retrospectively analyzed. The clinical data warehouse collected data including bowel preparation, insertion time, observation time, and the detection of polyps and adenomas. Multivariate regression analysis was performed to reveal the factors associated with endoscopic outcomes.Among 992 patients included in the study, 770 and 222 patients received PEG-AA and OSTs, respectively. Among the propensity score-matched population (n = 1897), OSTs resulted in better bowel cleansing quality (8.16 vs 7.84, p = 0.014) and a higher adenoma detection rate (38.6% vs 27.1%, p = 0.003). Using PEG-AA, older age, inadequate bowel preparation (BBPS score 6) and endoscopy by fellows were found to be factors associated with poor adenoma detection. In the elderly over 65 years of age, a significant difference in cleansing quality between the two groups (7.21 vs 8.19, p 0.001) was found, but its impact on ADR was not prominent (49.5% vs 45.4%, p = 0.653).OSTs with simethicone achieved better endoscopic cleanliness, improving adenoma detection rate compared to the conventional PEG-AA protocol. The synergistic effect of both the convenience of taking tablets and the reduction of intraluminal bubble by adjunctive simethicone improves the clinical efficacy of colonoscopy.

Sedation can resolve anxiety and fear in patients undergoing endoscopy. The use of sedatives has increased in Korea. Appropriate sedation is a state in which the patient feels subjectively comfortable while maintaining the airway reflex for stable spontaneous breathing. The patient should maintain a state of consciousness to the extent that he or she can cooperate with the needs of the medical staff. Despite its benefits, endoscopic sedation has been associated with cardiopulmonary complications. Cardiopulmonary complications are usually temporary. Most patients recover without sequelae. However, they may progress to serious complications, such as cardiovascular collapse. Therefore, it is essential to screen high-risk patients before sedation and reduce complications by meticulous monitoring. Additionally, physicians should be familiar with the management of emergencies. The first Korean clinical practice guideline for endoscopic sedation was developed based on previous worldwide guidelines for endoscopic sedation using an adaptation process. The guideline consists of nine recommendations based on a critical review of currently available data and expert consensus when the guideline was drafted. These guidelines should provide clinicians, nurses, medical school students, and policy makers with information on how to perform endoscopic sedation with minimal risk.

Background/Aims: The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions.Methods: This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction.Results: A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups.Conclusions: Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.

Background/Aims: This study aimed to determine the current status of facilities, equipment, and personnel for endoscopic sedation from endoscopy units of representative hospitals in South Korea.Methods: A questionnaire survey was conducted on 50 qualified endoscopy units accredited by the Korean Society of Gastrointestinal Endoscopy.Results: All included endoscopy units had regulations and educational programs regarding sedation training for endoscopists and nursing personnel. There present one assisting nurse during endoscopy in 35 units (70%) and at least two nurses in 12 units (24.0%). All endoscopy units had examination rooms equipped with oxygen supply and suction systems. Endoscopist-directed sedation was performed in 48 units (96.0%). Propofol-based sedation was the most used sedation method. All units had a separate recovery bay. The daily number of patients per bed was greater than 10 in 17 units (34.0%). In 26 (52.0%) units, a single nurse cared for ≥10 patients per day. All the units fulfilled the discharge criteria.Conclusions: This study presents data regarding endoscopic sedation clinical practice in 50 endoscopy units in South Korea. This study presents the current status of endoscopic sedation clinical practice in 50 qualified endoscopy units accredited by the KSGE, which provide excellent quality management.

Background The latest guidelines recommended that common bile duct stones (CBDSs) should be removed, preferably endoscopically, regardless of the presence of symptoms or complications. However, the removal of CBDSs may not be feasible in very old patients or those with co-morbidities. In these cases, it is important to understand the risk factors for the development of CBDSs-related complications to decide whether or not to treat high-risk patients. Herein, we aimed to identify the risk factors for the development of complications after the diagnosis of CBDSs. Methods The medical records of patients with CBDSs between October 2005 and September 2019 were retrospectively analyzed. All patients with radiologically-diagnosed CBDSs, including those who received treatment and those who did not, were analyzed. Results A total of 634 patients were included and 95 (15.0%) patients had CBDS-related complications during the mean follow-up period of 32.6 months. Forty-four (6.9%) high-risk patients remained asymptomatic and did not receive treatment during the follow-up period. In multivariate analyses, size of CBDSs ≥ 5 mm and no treatment within 30 days were independent risk factors for the development of complications. The spontaneous passage of CBDSs was proved radiologically in 9 out of 81 (11.1%) patients within 30 days. Conclusions It is recommended treating CBDSs within 30 days from the diagnosis, even in high-risk patients, especially if the size is larger than 5 mm.

Background/Aim: Endoscopic retrograde choangiopancreatography (ERCP) has been established as an effective tool for the diagnosis and treatment of pancreatobiliary diseases. However, after the evolution for more than 4 decades, nationwide data on current trends and characteristic is not well known. Therefore, we conducted an analysis of nationwide database to determine the number and status of ERCP performed in Korea. Methods: We used the nationwide claims database, Korean Health Insurance Review and Assessment between 2012 and 2015. We investigated the frequencies and characteristics of ERCP procedure performed as well as demographics of the patients. Results: A total of 158,038 ERCP procedures were performed in 114,757 patients during study period. The number of total ERCPs increased every year, and especially the rate of therapeutic ERCPs is on the increased trend. About two-thirds of ERCPs (63.3%) were performed in high-scaled hospitals. In 2015, the proportion of elderly patients over 80 years old increased compared to that in 2011, from 14.3% to 17.2%. Conclusions: The annual number of ERCPs performed is increasing in Korea. With increasing ERCP for therapeutic purposes or for older patients, more attention should be paid to safety for patients.

In this paper, we describe an optimal network location for travel planning (ONLTP) query, a type of optimal location query. In trip planning, finding the optimal point for a group of users is a fundamental problem in spatial group query processing. Many previous studies have considered the problem of finding the optimal point. However, their queries using an exact method perform efficiently only when the users are closely distributed, not spread out in large road networks. In contrast, approximation methods use two different spatial indices, but they cannot control the trade-off between query performance and accuracy. We propose a method using G-trees [1, 2] to remedy these drawbacks. Our exact method is a concrete implementation of the best-first search in G-trees, and our approximation method further reduces the visited nodes of the exact method.

Background: Malignant biliary obstruction (MBO) is usually caused by biliary tract cancer or pancreatic cancer. This study was performed to summarize the current situation regarding palliative endoscopic retrograde biliary drainage (ERBD) for MBO in Korea and to determine its clinical significance by analyzing representative nationwide data. Methods: Patients that underwent palliative ERBD for MBO between 2012 and 2015 were identified using the Health Insurance Review and Assessment database, which covers the entire Korean population. We assessed clinical characteristics and complications and compared the clinical impacts of initial metal and plastic stenting in these patients. Results: A total of 9,728 subjects (mean age, 65 ± 11.4 years; male, 61.4%) were identified and analyzed. The most common diagnosis was malignant neoplasm of liver and intrahepatic bile ducts (32.1%) and this was followed by extrahepatic or Ampulla of Vater cancer and pancreatic cancer. Initial plastic stent(s) placement was performed in 52.9% of the study subjects, and metal stent(s) placement was performed in 23.3%. The number of sessions of endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) was significantly higher in patients that underwent initial plastic stenting than in patients that underwent metal stenting (2.2 ± 1.7 vs 1.8 ± 1.4, P < 0.0001), but rates of post-ERCP pancreatitis, hospital days, and time to second ERCP or PTBD were not significantly different. Conclusion: This nationwide assessment study suggests that initial metal stenting is associated with fewer sessions of total ERCP or PTBD following the initial procedure, despite the preference for initial plastic stenting in Korea.

Background: Pulmonary thromboembolism (PTE) is one of the most important complications in cancer patients. Gastrointestinal cancers are at increased risk of PTE. However, there were few studies that predict pulmonary embolism using machine learning (ML) in cancer patients. The purpose of this study was to develop an ML based prediction model for PTE in gastrointestinal cancer patients, and to compare its performance with the conventional model. Methods: In a tertiary hospital, patients who underwent computed tomographic pulmonary angiography (CTPA) were reviewed retrospectively from 2010 to 2020. Demographic and predictor variables including the Wells score and D-dimer were investigated. ML was based on the random forest model. In the model comparison, the area under receiver operating curve (AUROC) was used to evaluate the predictive performance of each model.Results: A total of 446 gastrointestinal cancer patients were analyzed in this study. The overall incidence of PTE was 30.0%. PTE was the most common in pancreatic cancer (47.2%). Compared with the conventional model (AUROC 0.605), the performance of ML model predicting PTE was improved (0.706, P = 0.002) and was further improved with additional input of further demographic factors including age and sex (0.743, P < 0.001). The number of patients classified as requiring CTPA was significantly reduced according to the prediction with ML (1.8% vs 9.4%, P< 0.001).Conclusion: Prediction model based on ML might have advantages to improve the diagnostic performance and reduce the number of CTPA compared to the conventional model for PTE in patients with gastrointestinal cancer.

Background/Aims Combination of midazolam and opioids is used widely for endoscopic sedation. Compared with meperidine, fentanyl is reportedly associated with rapid recovery, turnover rate of endoscopy room, and quality of endoscopy. We compared fentanyl with meperidine when combined with midazolam for sedative colonoscopy. Methods A retrospective, cross-sectional, 1:2 matching study was conducted. Induction and recovery time were compared as the primary outcomes. Moreover, cecal intubation time, withdrawal time, total procedure time of colonoscopy, paradoxical reaction, adenoma detection rate, and adverse effect of midazolam or opioids were assessed as the secondary outcomes. Results A total of 129 subjects (43 fentanyl vs. 86 meperidine) were included in the analysis. The fentanyl group showed significantly more rapid induction time (4.5±2.7 min vs. 7.5±4.7 min, p

OBJECTIVES The objectives of this study were to describe the prevalence and seriousness of analgesic-induced adverse events (AEs) and to identify factors associated with serious analgesic-related AEs in Korea. METHODS Voluntarily reported analgesic-induced AEs to the Korea Adverse Event Reporting System from 2007 to 2016 were retrospectively reviewed. Analgesic medications were classified into nonopioids and opioids based on the Anatomical Therapeutic Chemical classification system. All AEs were grouped using System Organ Classes according to the World Health Organization-Adverse Reaction Terminology. Logistic regression was performed to identify factors associated with serious AEs. RESULTS Overall, 194,566 AEs (32.2% for nonopioids, 67.8% for opioids) were included in this analysis. The most common causative nonopioid and opioid analgesics was ketorolac (n = 10,789) and tramadol (n = 53,727), respectively. The most frequent AEs were skin and appendage disorders for nonopioids (31.8%) and gastrointestinal disorders (59.5%) for opioids. Serious AEs occurred in 6102 (9.7%) and 3326 (2.5%) cases of the nonopioid and opioid groups, respectively. The most common serious AEs were skin and appendage disorders (33.2%) for nonopioids and neurologic disorders (19.3%) for opioids. Serious AEs were significantly associated with male (odds ratio [OR] = 1.423), advanced age (OR = 1.570), certain causality (OR = 2.304), nonopioid analgesics (OR = 4.182), and polypharmacy (OR = 1.009; P

Background Although temporary endoscopic biliary stenting is considered effective for difficult common bile duct (CBD) stones, few studies have investigated the optimal conditions for complete stone clearance at the second endoscopic retrograde cholangiopancreatography (ERCP) after temporary biliary stenting. We aimed to evaluate factors associated with complete clearance. Methods Patients with difficult CBD stones (a large [≥ 20 mm] or multiple [≥ 3 sized ≥ 15 mm] CBD stones) were retrospectively enrolled from three institutions. Patients who underwent temporary biliary stenting at the first ERCP were analyzed. Double-pigtail plastic stents (7 or 10 Fr) were placed with the proximal ends above the stones. Complete clearance rate and stone size reduction at the second ERCP, and factors associated with complete clearance were evaluated using univariate and multivariate analyses. Results 85 patients were enrolled (mean age 74.5 years [SD 11.3]; 47 women). Stone size and CBD diameter significantly decreased during the interval. The overall complete stone clearance rate was 64.7 % (55/85) at the second ERCP. The mean stone size reduction was 5.6 mm (SD 6.8). In multivariate analysis, complete clearance rate was significantly lower in male patients, in patients aged > 80 years, and in stones > 25 mm initially, but was significantly higher when 7-Fr stents were placed and stone size was reduced by > 5 mm. Conclusion Use of 7-Fr rather than 10-Fr plastic stents was beneficial for complete clearance of difficult CBD stones after temporary biliary stenting; older male patients as well as patients with initial stones > 25 mm had a lower clearance rate.

The widespread use of mobile devices and social network services has made optimal location queries an important research topic. Previous studies have focused on the problem of maximum influential (Max-inf) location selection, that is, finding a location that can attract as many clients as possible. The location information of each client should be collected to process such a query. However, client location is considered sensitive information. Therefore, a privacy protection technique should be applied to Max-inf problems. Motivated by this, we propose a Max-inf problem query-processing technique with differentially private client location information. Furthermore, we present a Voronoi region-based technique to guarantee query accuracy and a Voronoi envelope-based pruning heuristic to improve query performance.

We previously reported that human cytomegalovirus (HCMV) 86 kDa immediate-early 2 gene product (IE86) promotes proteasome-dependent degradation of STING. In the present study, we determined the specific residues of IE86 responsible for STING degradation using a STING-firefly luciferase fusion protein expression system for quantitative meas-urement of STING protein levels. IE86 amino acids (aa) 136-289 were sufficient to promote STING degradation and further induced down-regulation of 2'3'-cyclic GMP-AMP (cGAMP)-mediated IFN-β promoter activation. Interestingly, transactivation domains (TAD) of the IE86 protein located at the N- and C-termini were required for down-regulation of Toll/interleukin-1 receptor (TIR) domain-containing adaptor-inducing interferon β (IFN-β) (TRIF)-mediated IFN-β-and p65/RelA-induced NF-κB-dependent promoter activation while amino acids (aa) 136-289 had no significant effects. Our collective data suggest that the IE86 protein utilizes the aa 136-289 region to promote STING degradation and inhibit the cGAS-STING pathway.

Polymeric microspheres containing magnesium hydroxide (MH) and a bioactive agent (BA), such as apocynin (APO) and astaxanthin (ATX), have been prepared as functional dermal fillers with enhanced physicochemical and biological performance. In this study, polycaprolactone (PCL)-based microspheres were produced with a uniform size of about 30-40 μm by utilizing a membrane emulsification device. MH from the PCL/MH microspheres effectively neutralized acidic products from PCL degradation. For

Efficacy of proton pump inhibitors is limited in patients with nonerosive reflux disease (NERD). The aim of this study was to comparatively evaluate the efficacy and safety of esomeprazole with sodium bicarbonate and esomeprazole alone.This was a multicenter, randomized, double-blind, active-controlled, noninferiority comparative study. A total of 379 patients with NERD were randomly allocated to receive either EsoduoA total of 355 patients completed the study (180 in the EsoduoEsoduo