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Berlic M, Korošec M, Remec ŽI, Čuk V, Battelino T, Repič Lampret B. Effect of antioxidant-rich kindergarten meals on oxidative stress biomarkers in healthy 5-6-year-old children: a randomized controlled trial. Eur J Pediatr 2024; 183:3085-3094. [PMID: 38658398 PMCID: PMC11192674 DOI: 10.1007/s00431-024-05576-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 04/26/2024]
Abstract
As children spend up to 9 h a day in kindergarten, the main purpose of our study was to evaluate the effect of antioxidant-rich kindergarten meals on oxidative stress biomarkers (OSBs) in healthy children. In the randomized control trial with a follow-up, healthy 5-6-year-old children from six kindergartens were randomly divided into a prototype group (PG, n = 40) and a control group (CG, n = 17). PG followed a 2-week antioxidant-rich kindergarten meal plan (breakfast, lunch, and two snacks), and CG followed their standard kindergarten meal plans. Outside the kindergartens, participants ate as usual. We used a consecutive 7-day dietary record inside and outside the kindergarten and the national dietary assessment tool OPEN to assess the total dietary antioxidant capacity (dTAC) of the consumed foods. Malondialdehyde (MDA), 8-hydroxy-2-deoxyguanosine (8-OHdG), and four F2-isoprostane were measured in fasting urine on days 1 and 15. We also measured total antioxidant power (PAT) and hydroperoxides (d-ROMs) in fasting serum on day 15 and obtained the value of the oxidative stress index (OSI). We used a Welch two-sample t-test and multiple regression analysis to compare the prototype and control groups and a nonparametric Wilcoxon signed rank exact test to compare pre- and post-intervention results in urine. Antioxidant-rich kindergarten meals contributed to a significantly (p < 0.05) higher intake of dTAC in PG participants compared to standard meals in CG participants (8.6 vs. 2.8 mmol/day). We detected a negative correlation between dTAC intake and d-ROMs and between dTAC intake and OSI (r = - 0.29, p = 0.043 and r = - 0.31, p = 0.032, respectively). A significant decrease in urinary 8-iso-15-prostaglandin-F-2 alpha was detected in PG participants between days 1 and 15; however, no other intra-individual significant differences in urinary OSBs were found. Conclusion: Antioxidant-rich food in kindergarten is warranted due to its potential health-protective effect. Additionally, we present original data on the average levels of urinary and serum OSBs in healthy 5-6-year-old children. Trial registration: The study was registered at ClinicalTrials.gov, on February 5, 2020 ( https://clinicaltrials.gov/ct2/show/NCT04252105 ). What is Known: • Kindergartens are recognized as promising environments for public health measures. • A diet rich in antioxidants can reduce OSBs and, consequently, the risk of developing NCDs. What is New: • Antioxidant-rich kindergarten diet can ensure a protective intake of dTAC in children. • Original data on serum oxidative stress biomarkers (d-ROMs, PAT, and OSI) and urinary oxidative stress biomarkers (MDA, 8-OHdG, and F2 isoprostanes) in healthy 5-6-year-old children.
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Affiliation(s)
- Maja Berlic
- Department of Food Science and Technology, Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Preschool Galjevica, Ljubljana, Slovenia
| | - Mojca Korošec
- Department of Food Science and Technology, Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Žiga Iztok Remec
- Clinical Institute for Special Laboratory Diagnostics, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Vanja Čuk
- Clinical Institute for Special Laboratory Diagnostics, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Barbka Repič Lampret
- Clinical Institute for Special Laboratory Diagnostics, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia.
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Yousef H, Khandoker AH, Feng SF, Helf C, Jelinek HF. Inflammation, oxidative stress and mitochondrial dysfunction in the progression of type II diabetes mellitus with coexisting hypertension. Front Endocrinol (Lausanne) 2023; 14:1173402. [PMID: 37383391 PMCID: PMC10296202 DOI: 10.3389/fendo.2023.1173402] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/26/2023] [Indexed: 06/30/2023] Open
Abstract
Introduction Type II diabetes mellitus (T2DM) is a metabolic disorder that poses a serious health concern worldwide due to its rising prevalence. Hypertension (HT) is a frequent comorbidity of T2DM, with the co-occurrence of both conditions increasing the risk of diabetes-associated complications. Inflammation and oxidative stress (OS) have been identified as leading factors in the development and progression of both T2DM and HT. However, OS and inflammation processes associated with these two comorbidities are not fully understood. This study aimed to explore changes in the levels of plasma and urinary inflammatory and OS biomarkers, along with mitochondrial OS biomarkers connected to mitochondrial dysfunction (MitD). These markers may provide a more comprehensive perspective associated with disease progression from no diabetes, and prediabetes, to T2DM coexisting with HT in a cohort of patients attending a diabetes health clinic in Australia. Methods Three-hundred and eighty-four participants were divided into four groups according to disease status: 210 healthy controls, 55 prediabetic patients, 32 T2DM, and 87 patients with T2DM and HT (T2DM+HT). Kruskal-Wallis and χ2 tests were conducted between the four groups to detect significant differences for numerical and categorical variables, respectively. Results and discussion For the transition from prediabetes to T2DM, interleukin-10 (IL-10), C-reactive protein (CRP), 8-hydroxy-2'-deoxyguanosine (8-OHdG), humanin (HN), and p66Shc were the most discriminatory biomarkers, generally displaying elevated levels of inflammation and OS in T2DM, in addition to disrupted mitochondrial function as revealed by p66Shc and HN. Disease progression from T2DM to T2DM+HT indicated lower levels of inflammation and OS as revealed through IL-10, interleukin-6 (IL-6), interleukin-1β (IL-1β), 8-OHdG and oxidized glutathione (GSSG) levels, most likely due to antihypertensive medication use in the T2DM +HT patient group. The results also indicated better mitochondrial function in this group as shown through higher HN and lower p66Shc levels, which can also be attributed to medication use. However, monocyte chemoattractant protein-1 (MCP-1) levels appeared to be independent of medication, providing an effective biomarker even in the presence of medication use. The results of this study suggest that a more comprehensive review of inflammation and OS biomarkers is more effective in discriminating between the stages of T2DM progression in the presence or absence of HT. Our results further indicate the usefulness of medication use, especially with respect to the known involvement of inflammation and OS in disease progression, highlighting specific biomarkers during disease progression and therefore allowing a more targeted individualized treatment plan.
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Affiliation(s)
- Hibba Yousef
- Department of Biomedical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Ahsan H. Khandoker
- Department of Biomedical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Samuel F. Feng
- Department of Science and Engineering, Sorbonne University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Charlotte Helf
- Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Schleswig-Holstein, Germany
| | - Herbert F. Jelinek
- Department of Biomedical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, Abu Dhabi, United Arab Emirates
- Biotechnology Center, Khalifa University, Abu Dhabi, United Arab Emirates
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Husain S, Hillmann K, Hengst K, Englert H. Effects of a lifestyle intervention on the biomarkers of oxidative stress in non-communicable diseases: A systematic review. FRONTIERS IN AGING 2023; 4:1085511. [PMID: 36970730 PMCID: PMC10034086 DOI: 10.3389/fragi.2023.1085511] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/27/2023] [Indexed: 03/11/2023]
Abstract
Oxidative stress plays a critical role in the pathogenesis of chronic diseases. Therefore, improvement of oxidative stress status through lifestyle intervention can play a vital role in preventing and treating chronic diseases. This systematic review aims to provide an overview of articles published in the last decade examining the association between lifestyle intervention and oxidative stress biomarkers in the context of non-communicable diseases. The electronic databases PubMed and Web of Science were searched for relevant studies, following the PRISMA (Preferred Reporting of Systematic Reviews and Meta-Analyses) guidelines. This systematic review focused on the four important oxidative stress biomarkers; glutathione (GSH), superoxide dismutase (SOD), catalase, and malondialdehyde. 671 articles were identified, of which nine met the inclusion criteria. A trend emerged, showing that lifestyle modifications that focus on diet and physical health can improve oxidative stress in the form of an increase in superoxide dismutase and CAT levels and a decrease in Malondialdehyde levels in participants with non-communicable diseases (NCDs), GSH levels were not affected. However, the results are difficult to compare because of the heterogeneity of the methods of the biomarkers studied. Our review indicates that oxidative stress can be influenced by lifestyle modifications and may be an effective tool for the prevention and management of non-communicable diseases. This review also elucidated the importance of analyzing multiple oxidative stress biomarkers to evaluate oxidative stress, it further highlights the need to conduct long-term lifestyle intervention studies on oxidative stress biomarkers to understand the connection between oxidative stress biomarkers, NCDs and Lifestyle intervention.
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Affiliation(s)
- Sarah Husain
- Faculty of Medicine, University of Muenster (WWU), Münster, Germany
- Department of Food, Nutrition and Facilities, University of Applied Sciences Muenster, Münster, Germany
- *Correspondence: Sarah Husain,
| | | | - Karin Hengst
- Department of medicine, University hospital Muenster (UKM), Münster, Germany
| | - Heike Englert
- Faculty of Medicine, University of Muenster (WWU), Münster, Germany
- Department of Food, Nutrition and Facilities, University of Applied Sciences Muenster, Münster, Germany
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Antioxidant Activity and Reactive Oxygen Species (ROS) Scavenging Mechanism of Eriodictyon californium, an Edible Herb of North America. J CHEM-NY 2022. [DOI: 10.1155/2022/6980121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Modern life associated with processed food, exposure to a wide range of pollutants, physical inactivity, unprecedented time, excessive involvement of technology in our lives, and so on give rise to oxidative stress which threatens our physical and mental health. Because of rising healthcare costs and mistrust of conventional medicine, mankind is looking for alternatives to over-the-counter medications and prescription drugs, which is driving the demand for nutraceuticals across the globe. Antioxidant-rich plant-based natural products could be an important source of nutraceuticals to boost endogenous antioxidant levels. In this research, we uncovered the antioxidant potential of Eriodictyon californicum, an herb used by Native Americans for centuries to treat a wide range of ailments. The ethanolic leaf extract of E. californicum was studied for its phytochemical constituents, antioxidant potential, and free radical scavenging activity. Phytochemical analysis revealed the presence of flavonoids, saponins, phenols, tannins, terpenoids, cardiac glycosides, and steroids. The abundance of total phenol (78.58 ± 0.016 μg GAE/mg) and flavonoid content (6.76 ± 0.003 μg QE/mg) and the strong reducing activity in the FRAP assay indicated the antioxidant potential of the leaves. Free radical scavenging activity was confirmed by a dose-dependent response on the DPPH assay (IC50 0.071 mg/mL). Since reactive oxygen species are the main culprits for causing oxidative stress in our body, studying the effect of plant extracts on superoxide, hydrogen peroxide, and hydroxyl radicals found that it has the ability to neutralize all three. IC50 was found to be 0.083 mg/mL for superoxide radicals, 0.033 mg/mL for hydrogen peroxide, and 0.080 mg/mL for hydroxyl radicals. Herein, we report that E. californicum is a potential source of bioactive components with strong radical scavenging activity. This holy herb could serve as a healing agent against oxidative stress and holds promise for the development of nutraceuticals.
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Comparison of Five Oxidative Stress Biomarkers in Vegans and Omnivores from Germany and Finland. Nutrients 2022; 14:nu14142918. [PMID: 35889875 PMCID: PMC9323774 DOI: 10.3390/nu14142918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/13/2022] [Accepted: 07/13/2022] [Indexed: 02/01/2023] Open
Abstract
When the amount of reactive oxygen species produced by human metabolism cannot be balanced by antioxidants, this phenomenon is commonly referred to as oxidative stress. It is hypothesised that diets with high amounts of plant food products may have a beneficial impact on oxidative stress status. However, few studies have examined whether a vegan diet is associated with lower oxidative stress compared to an omnivorous diet. The present cross-sectional study aimed to compare the levels of five oxidative stress biomarkers in vegans and omnivores. Data of 36 vegans and 36 omnivores from Germany and of 21 vegans and 18 omnivores from Finland were analysed. HPLC coupled with mass spectrometry or fluorescence detection and ELISA methods were used to measure the oxidative stress biomarkers malondialdehyde (MDA), protein carbonyls and 3-nitrotyrosine in plasma and 8-hydroxy-2'-deoxyguanosine (8-OHdG) and 8-iso-prostaglandin F2α (8-iso-PGF2α) in 24 h urine. Analyses of variance and covariance, considering potential confounders, were used. Vegans and omnivores showed no differences in MDA and protein carbonyl concentrations. In Finnish but not in German vegans, the concentrations of 3-nitrotyrosine were lower compared to those in omnivores (p = 0.047). In Germany, vegans showed lower excretion levels of 8-iso-PGF2α than omnivores (p = 0.002) and with a trend also of 8-OHdG (p = 0.05). The sensitivity analysis suggests lower 8-iso-PGF2α excretion levels in women compared to men, independently of the dietary group. The present study contributes to expanding our knowledge of the relationship between diet and oxidative stress and showed that 3-nitrotyrosine, 8-OHdG and 8-iso-PGF2α tended to be lower in vegans. Furthermore, studies are recommended to validate the present findings.
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Henning T, Weber D. Redox biomarkers in dietary interventions and nutritional observation studies - From new insights to old problems. Redox Biol 2021; 41:101922. [PMID: 33756398 PMCID: PMC8020480 DOI: 10.1016/j.redox.2021.101922] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose The purpose of this review is to give an overview on recently published articles investigating the associations of diet and dietary interventions with biomarkers of oxidative stress with special emphasis on different categories of redox biomarkers. Findings Intervention and observational studies both in healthy participants and patients that investigated associations of dietary habits, foodstuffs or isolated nutrients with biomarkers of oxidative stress were included in this review. Recently published observation studies confirm the inverse association between fruit and vegetable intake and oxidative stress markers. Studies investigating the effect of vitamin D and vitamin E, magnesium, zinc, chromium, selenium, probiotic supplementation and several phytochemicals reported consistent changes in redox biomarkers. Of 88 articles included in this review, only seven studies measured biomarkers from the three categories: oxidative damage, endogenous antioxidants, and exogenous antioxidants. Many studies rely on controversial assays for total antioxidant capacity, thus there is potential in many studies to improve biomarker repertoire to cover all three categories of biomarkers and to turn away from such assays. Oxidative stress can be assessed by specific biomarker categories. Three biomarker categories: oxidative damage, endogenous, exogenous antioxidants. Only seven studies performed measurements of all three biomarker categories. TAC, TRAP, FRAP, ORAC should not be used as stand-alone redox marker. Several interventions reported improvements in markers of oxidative stress.
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Affiliation(s)
- Thorsten Henning
- Department of Molecular Toxicology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), 14558, Nuthetal, Germany; Food4Future (F4F), c/o Leibniz Institute of Vegetable and Ornamental Crops (IGZ), Theodor-Echtermeyer-Weg 1, 14979, Grossbeeren, Germany
| | - Daniela Weber
- Department of Molecular Toxicology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), 14558, Nuthetal, Germany; Food4Future (F4F), c/o Leibniz Institute of Vegetable and Ornamental Crops (IGZ), Theodor-Echtermeyer-Weg 1, 14979, Grossbeeren, Germany; NutriAct-Competence Cluster Nutrition Research Berlin-Potsdam, 14558, Nuthetal, Germany.
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Outcomes Assessment of Sustainable and Innovatively Simple Lifestyle Modification at the Workplace - Drinking Electrolyzed-Reduced Water (OASIS-ERW): A Randomized, Double-Blind, Placebo-Controlled Trial. Antioxidants (Basel) 2020; 9:antiox9070564. [PMID: 32605142 PMCID: PMC7402115 DOI: 10.3390/antiox9070564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/30/2020] [Accepted: 05/30/2020] [Indexed: 02/07/2023] Open
Abstract
Oxidative stress has been associated with many diseases as well as aging. Electrolyzed-reduced water (ERW) has been suggested to reduce oxidative stress and improve antioxidant potential. This study investigated the effects of drinking ERW on biomarkers of oxidative stress and health-related indices in healthy adults. We conducted a randomized, double-blind, placebo-controlled clinical trial on 65 participants, who were allocated into two groups. Of these, 61 received intervention (32 with ERW and 29 MW [mineral water]). All participants were instructed to drink 1.5 L/day of ERW or MW for eight weeks. Biomarkers of oxidative stress and health-related indices were assessed at baseline as well as after 4 weeks and 8 weeks of intervention. Of the primary outcome variables assessed, diacron-reactive oxygen metabolites (d-ROMs) and biological antioxidant potential showed a significant interaction between the groups and time, with d-ROMs levels significantly decreased at 8 weeks in ERW compared to those in MW. Among the secondary outcome variables, total, visceral, and subcutaneous fat mass significantly changed over time, with a significant association observed between the groups and time. Thus, daily ERW consumption may be a potential consideration for a sustainable and innovatively simple lifestyle modification at the workplace to reduce oxidative stress, increase antioxidant potential, and decrease fat mass.
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Inhibition of copper-induced lipid peroxidation by sinapic acid and its derivatives in correlation to their effect on the membrane structural properties. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2019; 1861:1-8. [DOI: 10.1016/j.bbamem.2018.10.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/28/2018] [Accepted: 10/11/2018] [Indexed: 01/29/2023]
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Kim YS, Kim M, Choi MY, Lee DH, Roh GS, Kim HJ, Kang SS, Cho GJ, Hong EK, Choi WS. Alpha-lipoic acid reduces retinal cell death in diabetic mice. Biochem Biophys Res Commun 2018; 503:1307-1314. [PMID: 30017190 DOI: 10.1016/j.bbrc.2018.07.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/08/2018] [Indexed: 12/30/2022]
Abstract
Oxidative stress plays an important role in the development of diabetic retinopathy. Here, we examined whether α-lipoic acid (α-LA), a natural antioxidant, attenuated retinal injury in diabetic mice. The α-LA was orally administered to control mice or mice with streptozotocin-induced diabetes. We found that α-LA reduced oxidative stress, decreased and increased retinal 4-hydroxy-2-nonenal and glutathione peroxidase, respectively, and inhibited retinal cell death. Concomitantly, α-LA reversed the decreased activation of AMP-activated protein kinase (AMPK) and acetyl-CoA carboxylase, and increased the levels of peroxisome proliferator-activated receptor delta and sirtuin3 in diabetic mouse retinas, similar to results shown after metformin treatment of retinal pigment epithelial cells (RPE) exposed to high glucose. Moreover, α-LA lowered the levels of O-linked β-N-acetylglucosamine transferase (OGT) and thioredoxin-interacting protein (TXNIP) in diabetic retinas that were more pronounced after metformin treatment of RPE cells. Importantly, α-LA lowered interactions between AMPK and OGT as shown by co-immunoprecipitation analyses, and this was accompanied by less cell death as measured by double immunofluorescence staining by terminal deoxynucleotide transferase-mediated dUTP nick-end labelling and OGT or TXNIP in retinal ganglion cells. Consistently, α-LA lowered the levels of cleaved poly(ADP-ribose) polymerase and pro-apoptotic marker cleaved caspase-3 in diabetic retinas. Our results indicated that α-LA reduced retinal cell death partly through AMPK activation or OGT inhibition in diabetic mice.
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Affiliation(s)
- Yoon Sook Kim
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Minjun Kim
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Mee Young Choi
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Dong Hoon Lee
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Gu Seob Roh
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Hyun Joon Kim
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Sang Soo Kang
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Gyeong Jae Cho
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea
| | - Eun-Kyung Hong
- Medvill Co., Ltd, 1606 Daeryung Post Tower 5th, 68 Digitalro 9gil, Guemcheon-gu, Seoul, 08512, Republic of Korea
| | - Wan Sung Choi
- Department of Anatomy and Convergence Medical Science, Institute of Health Science, Gyeongsang National University School of Medicine, Jinju, Gyeongnam, Republic of Korea.
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