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Background: The risk of developing lung cancer is increased in smokers, patients with chronic obstructive pulmonary disease, individuals exposed to environmental carcinogens, and those with a history of lung cancer. Automobile exhaust fumes containing carcinogens are a risk factor for lung cancer. However, we go through life unaware of the fact that automobile exhaust is the cause of cancer. Especially, in lung cancer patient, it is important to search out pre-existing risk factors and advice to avoid them, and monitor carefully for recurrence after treatment., Case Presentation: This is the first report of a case with triple lung cancers with different histologic types at different sites, observed in a 76-year-old parking attendant. The first adenocarcinoma and the second squamous cell carcinoma were treated with stereotactic radiosurgery because the patient did not want to undergo surgery. Although the patient stopped intermittent smoking after the diagnosis, he continued working as a parking attendant in the parking lot. After 29 months from the first treatment, the patient developed a third new small cell lung cancer; he was being treated with chemoradiation., Conclusions: New mass after treatment of lung cancer might be a multiple primary lung cancer rather than metastasis. Thus, precision evaluation is important. This paper highlights the risk factors for lung cancer that are easily overlooked but should not be dismissed, and the necessity of discussion with patients for the surveillance after lung cancer treatment. We should look over carefully the environmental carcinogens already exposed, and counsel to avoid pre-existing lung cancer risk factors at work or residence in patients with lung cancer., (© 2022. The Author(s).)

Rationale: Cryptococcus neoformans (C neoformans) infection typically occurs in immunocompromised patients infected with human immunodeficiency virus (HIV), or those taking immunosuppressive drugs, corticosteroids, or chemotherapy. Recently, there have been an increasing number of reports of cryptococcosis as opportunistic infections in COVID-19 patients, all of which have been related to immunocompromising conditions, underlying medical diseases, immune suppression drugs, or corticosteroids. Here, we report the first case of pulmonary cryptococcosis in an immunocompetent patient with a history of COVID-19 who had no history of underlying diseases or immune modulation drugs., Patient Concerns: A previously healthy 46-year-old man presented with tiny lung nodules. He had quit smoking 6 years prior. He had no significant medical history except for COVID-19 3 months prior, and had not received corticosteroids or cytokine blockers when he had COVID-19. He had been coughing since he recovered from COVID-19., Diagnosis: Bronchoalveolar lavage cultures showed the growth of C neoformans. A CT-guided percutaneous needle biopsy of the lung lesion was performed. Histopathology of the biopsy specimen showed granulomas with encapsulated yeast. There was no growth of C neoformans in the CSF or blood. He was diagnosed with pulmonary cryptococcosis., Intervention: Antifungal drug (fluconazole) was administered for 6 months in the outside clinic., Outcomes: The lung lesions disappeared after 6 months medication., Lessons: This case may illustrate the risk of pulmonary cryptococcosis after SARS-CoV-2 infection in an immunocompetent patient. Opportunistic infections can occur even after recovery from COVID-19 for several reasons. First, SARS-CoV-2 infection causes immune dysregulation including lymphocytopenia. Second, T lymphocytes play a principal role against Cryptococcus. Third, these changes in the immune system due to COVID-19 may last for several weeks. Thus, we suggest careful consideration of lung lesions in patients with a history of COVID-19., Competing Interests: The author has no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Following the humidifier disinfectant incident in Korea, polyhexamethylene guanidine phosphate (PHMG-P) has been used to establish lung fibrosis model animals. Herein, we investigated time-dependent changes after a single PHMG-P instillation (22 μg/lung) to identify the underlying pathogenesis and immune response involved in PHMG-P-induced lung fibrosis. Compared to control mice, body weight loss and blood biochemical and hematological changes were more remarkable in PHMG-P-instilled mice, an increase of total cell counts, infiltration of macrophages and neutrophils and necrotic cell death were also more notable in the lungs of PHMG-P-instilled mice. Pathological lesions were detected from Day 1 after exposure, deteriorating with time. In addition, secretion of anti-inflammatory mediators was rapidly inhibited from 6 h after exposure, and level of IL-24, a tissue repair-related cytokine, was up-regulated in the lungs of PHMG-P-instilled mice until Day 21 post-exposure. In vitro tests using BEAS-2B cells showed that PHMG-P disturbed structural and functional homeostasis of organelles and that intracellular ROS increase was considered as an important cause of PHMG-P-induced cell death. Additionally, co-culture with DNA, a polyanionic compound, clearly inhibited PHMG-P-induced necrosis, and increased IL-1β and TNF-α level and decreased IL-6 and IL-8 levels were observed following exposure to PHMG-P. Meanwhile, IL-8 secretion increased in cells exposed to PHMG-P-induced cell debris. Therefore, we suggest that necrotic cell debris may importantly contribute to the PHMG-P-induced inflammatory response and pathogenesis. In addition, PHMG-P-induced necrosis may be initiated by high affinity between PHMG-P and cell membrane., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Anticoagulation during extracorporeal membrane oxygenation (ECMO) usually is required to prevent thrombosis. The aim of this study was to investigate the usefulness of nafamostat mesilate (NM) as a regional anticoagulant during veno-arterial ECMO (VA-ECMO) treatment., Methods: We retrospectively reviewed the medical records of 16 patients receiving VA-ECMO and NM from January 2017 to June 2020 at Haeundae Paik Hospital. We compared clinical and laboratory data, including activated partial thromboplastin time (aPTT), which was measured simultaneously in patients and the ECMO site, to estimate the efficacy of regional anticoagulation., Results: The median patient age was 68.5 years, and 56.3% of patients were men. Cardiovascular disease was the most common primary disease (75.0%) requiring ECMO treatment, followed by respiratory disease (12.5%). The median duration of ECMO treatment was 7.5 days. Among 16 patients, seven were switched to NM after first using heparin as an anticoagulation agent, and nine received only NM. When comparing aPTT values in the NM group between patients and the ECMO site, that in patients was significantly lower than that at the ECMO site (73.57 vs. 79.25 seconds; P=0.010); in contrast, no difference was observed in the heparin group., Conclusions: NM showed efficacy as a regional anticoagulation method by sustaining a lower aPTT value compared to that measured at the ECMO site. NM should be considered as a safer regional anticoagulation method in VA-ECMO for patients at high risk of bleeding.

Background: The Korea Interstitial Lung Disease Study Group has made a new nationwide idiopathic pulmonary fibrosis (IPF) registry because the routine clinical practice has changed due to new guidelines and newly developed antifibrotic agents in the recent decade. The aim of this study was to describe recent clinical characteristics of Korean IPF patients., Methods: Both newly diagnosed and following IPF patients diagnosed after the previous registry in 2008 were enrolled. Survival analysis was only conducted for patients diagnosed with IPF after 2016 because antifibrotic agents started to be covered by medical insurance of Korea in October 2015., Results: A total of 2,139 patients were analyzed. Their mean age at diagnosis was 67.4±9.3 years. Of these patients, 76.1% were males, 71.0% were ever-smokers, 14.4% were asymptomatic at the time of diagnosis, and 56.9% were at gender-agephysiology stage I. Occupational toxic material exposure was reported in 534 patients. The mean forced vital capacity was 74.6% and the diffusing capacity for carbon monoxide was 63.6%. Treatment with pirfenidone was increased over time: 62.4% of IPF patients were treated with pirfenidone initially. And 79.2% of patients were treated with antifiboritics for more than three months during the course of the disease since 2016. Old age, acute exacerbation, treatment without antifibrotics, and exposure to wood and stone dust were associated with higher mortality., Conclusion: In the recent Korean IPF registry, the percentage of IPF patients treated with antifibrotics was increased compared to that in the previous IPF registry. Old age, acute exacerbation, treatment without antifibrotics, and exposure to wood and stone dust were associated with higher mortality.

Purpose: Vitamin D insufficiency or deficiency is prevalent in patients with chronic obstructive pulmonary disease (COPD). However, the association between vitamin D levels and respiratory symptoms in patients with stable COPD has not been fully investigated. This study evaluated the association between vitamin D levels and respiratory symptoms in patients with stable COPD., Patients and Methods: Patients with COPD who had their serum 25-hydroxyvitamin D (25-OH vitamin D) level measured within 6 months of spirometry between January 2016 and April 2020 were retrospectively included. Respiratory symptoms were assessed using the modified Medical Research Council (mMRC) scale and COPD assessment test (CAT) score., Results: Of the 329 included patients, 193, 88, and 48 were categorized as having vitamin D deficiency (<20 ng/mL), insufficiency (20-29 ng/mL), and sufficiency (≥30 ng/mL), respectively. The mean serum 25-OH vitamin D level of each group was 13.45 ng/mL, 24.61 ng/mL, and 38.90 ng/mL, respectively. Patients with vitamin D insufficiency/deficiency showed higher CAT scores than those with vitamin D sufficiency ( p = 0.004). In multivariable adjusted models, vitamin D insufficiency/deficiency was significantly associated with a CAT score of 10 or more (adjusted odds ratio [aOR] = 2.41, 95% confidence interval [CI] = 1.20-4.82, p = 0.013) and mMRC ≥ 2 (aOR = 2.39, 95% CI = 1.08-5.32, p = 0.032). Among CAT items, the amount of phlegm ( p = 0.008), chest tightness ( p = 0.030), breathlessness walking upstairs ( p < 0.001), home activity limitations ( p = 0.002), and lack of energy ( p = 0.003) were significantly associated with vitamin D insufficiency/deficiency after adjustment for age, sex, body mass index, smoking history, Charlson comorbidity index, post-bronchodilator forced expiratory volume in 1 second, and season of blood draw., Conclusion: Vitamin D insufficiency/deficiency were associated with worse respiratory symptoms in patients with stable COPD., Competing Interests: The authors report no conflicts of interest in this work., (© 2022 Lee et al.)

Background: Chronic bronchitis (CB) is associated with poor outcomes in patients with chronic obstructive pulmonary disease. The aim of this study was to identify the characteristics that distinguish chronic bronchitis (CB) from non-CB. In addition, the features of mild CB versus severe CB were compared and a cut-off level was defined according to CAT1 and CAT2 scores., Methods: This study was based on the Korea COPD Subgroup Study (KOCOSS) database, constructed in a multicenter COPD cohort study that recruited patients from 54 centers. CB was defined as CAT1 and CAT2 scores ≥ 3; severe CB was defined as CAT1 and CAT2 scores ≥ 4, while mild CB was defined as either a CAT1 or a CAT2 score < 4. Baseline characteristics, 1-year exacerbation rate, and 3-year FEV 1 decline were compared in non-CB versus CB patients and in patients with mild CB versus severe CB., Results: Among the 2162 patients enrolled in this study, 497 (23%) had CB. These patients were more likely than non-CB patients to be current smokers; they also had higher symptom and depression/anxiety scores. Lung function tests showed lower FEV 1 , FEV 1 /FVC, and DLco values in CB patients. Among CB patients, 67.6% had mild disease. Symptom and depression/anxiety scores were worse in patients with severe CB than in patients with mild CB. There were no significant differences in the lung function tests of the two groups. Analysis of 1-year exacerbation rates in CB patients and non-CB patients revealed that patients with CB more frequently had moderate-to-severe exacerbations (OR = 1.46, p < 0.01). More severe exacerbation was also present in patients with severe CB than in patients with mild CB (OR = 2.52, p = 0.01). The difference in annual FEV 1 decline rate did not significantly differ either between CB patients and non-CB patients or between patients with severe CB and patients with mild CB., Conclusions: CB patients had worse symptoms and lung function than non-CB patients; CB patients also had more frequent moderate-to-severe exacerbation. Patients with severe CB had higher symptom scores and more frequent severe exacerbation than did patients with mild CB., (© 2022. The Author(s).)

Background: This pilot study aimed to investigate the current status of e-cigarettes (ECs) use patterns among patients with chronic airway disease or chronic respiratory symptoms and the effects of ECs use on respiratory and mental health., Methods: A cross-sectional survey was conducted at the outpatient clinic of eight teaching hospitals in South Korea between November 2019 and December 2019. All adult ECs users (19 years and above) who visited the outpatient clinic as a patient with chronic airway disease or chronic respiratory symptoms were eligible to participate in this study., Results: A total of 51 subjects responded to the survey. Most of the participants were male (92.2%) and the mean age was 41.8 years. Dominant airway diseases were asthma and chronic obstructive pulmonary disease. Most of the subjects had a history of cigarette smoking, and 19 subjects were dual users of current cigarettes and ECs. Most of the subjects started ECs use due to health-related reasons. When comparing exclusive ECs users and dual users, St. George's respiratory questionnaire (SGRQ) scores, the proportion of cases with moderate to severe depressive symptoms, and average Fagerstrom test for nicotine dependence scores for ECs were higher in dual users than exclusive ECs users (mean 4.64 vs. 2.38, p = 0.006), respectively., Conclusion: Most of the subjects started ECs use due to health concerns, but dual users have more respiratory symptoms and higher nicotine dependence in this pilot study. One hypothesis that comes from these results is that greater nicotine dependence may influence behaviours, habits, and views about ECs. These preliminary observations need confirmation in a large cohort., (© 2021 The Authors. The Clinical Respiratory Journal published by John Wiley & Sons Ltd.)

Background: This study aimed to investigate the association between e-cigarette (EC) use and development of acute severe pneumonia in the Korean population using a national database., Methods: We conducted a retrospective analysis using linkage of data between the Korean National Health and Nutrition Examination Survey (KNHANES) and the National Health Insurance Service (NHIS) administrative claims database. The primary endpoint of this study was development of severe pneumonia requiring hospital admission according to EC use during the study period. The secondary endpoints were in-hospital mortality, intensive care unit (ICU) admission, ventilator care, and days of hospital stay., Results: The final analysis included 28,950 individuals, of which 578 (2.0%) were EC users. EC users were younger and more often male than non-EC users. The EC users showed higher level of education and household income and had fewer comorbidities. Severe pneumonia was noted in 37 of 28,372 non-EC users (0.13%), but there were no occurrences of severe pneumonia in EC users. The incidence of pneumonia occurrence was not different between the two groups ( P = 1.000)., Conclusions: Since e-cigarette or vaping use-associated lung injury (EVALI) is most likely included in acute severe pneumonia occurring within 3 months of EC use, it is considered that there might be no EVALI patients in Korea during the investigation period. A large-scale, prospective study is necessary to evaluate the association between EC use and acute lung injury., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2021 The Korean Academy of Medical Sciences.)

Objectives: There have been few clinical studies of ECMO-related alterations of the PK of meropenem and conflicting results were reported. This study investigated the pharmacokinetics (PK) of meropenem in critically ill adult patients receiving extracorporeal membrane oxygenation (ECMO) and used Monte Carlo simulations to determine appropriate dosage regimens. Methods: After a single 0.5 or 1 g dose of meropenem, 7 blood samples were drawn. A population PK model was developed using nonlinear mixed-effects modeling. The probability of target attainment was evaluated using Monte Carlo simulation. The following treatment targets were evaluated: the cumulative percentage of time during which the free drug concentration exceeds the minimum inhibitory concentration of at least 40% (40% fT >MIC ), 100% fT >MIC , and 100% fT >4xMIC . Results: Meropenem PK were adequately described by a two-compartment model, in which creatinine clearance and ECMO flow rate were significant covariates of total clearance and central volume of distribution, respectively. The Monte Carlo simulation predicted appropriate meropenem dosage regimens. For a patient with a creatinine clearance of 50-130 ml/min, standard regimen of 1 g q8h by i. v. infusion over 0.5 h was optimal when a MIC was 4 mg/L and a target was 40% fT >MIC . However, the standard regimen did not attain more aggressive target of 100% fT >MIC or 100% fT >4xMIC . Conclusion: The population PK model of meropenem for patients on ECMO was successfully developed with a two-compartment model. ECMO patients exhibit similar PK with patients without ECMO. If more aggressive targets than 40% fT >MIC are adopted, dose increase may be needed., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lee, Lee, Kim, Jung, Heo, Kim, Kim, No, Jo, Ko, Lee, Jun, Choi, Jang and Jang.)

Rationale: In recent decades, diagnosis and treatment recommendations for idiopathic pulmonary fibrosis (IPF) have changed. In Korea, the average life expectancy has increased, unmet healthcare needs have been reduced, and the number of computed tomographic examinations performed has nearly doubled. The Korean Interstitial Lung Disease Study Group conducted a nationwide cohort study for idiopathic interstitial pneumonia, including IPF, and established a registry for IPF. Objectives: Using study data collected by the study group, this study aimed to evaluate longitudinal changes in clinical features, diagnosis, treatment, and mortality and analyze the extent to which changes in medication usage affected IPF-associated mortality. Methods: The study population included newly diagnosed patients with IPF from a cohort study (January 2002 to September 2008, n  = 1,839, 2008 group) and prospective registry (January 2012 to August 2018, n  = 1,345, 2018 group). Survival curves were estimated using the Kaplan-Meier method, and Cox regression models were used to identify mortality-associated risk factors in each group. Results: The 2018 group was younger, had fewer symptoms, had less honeycombing, underwent more serologic autoimmune marker and pulmonary function tests, had higher oxygen partial pressure and lower carbon dioxide partial pressure values, was less frequently diagnosed by surgical biopsy, and had better survival than the 2008 group. Steroid use and conservative care declined, whereas N -acetylcysteine use increased in this group. Antifibrotic agents were used in only the 2018 group. In the 2008 group, N -acetylcysteine was associated with lower mortality, whereas conservative care was associated with higher mortality. In the 2018 group, the use of antifibrotic agents was associated with lower mortality, and steroid use was associated with higher mortality. The survival rates in the 2008 and 2018 non-antifibrotic agent subgroups were similar. Conclusions: This study analyzed national IPF cohort data spanning 17 years. In clinical practice, the IPF diagnosis was made earlier, steroid and immunosuppressive agent use was reduced, and antifibrotic agents were administered. The survival of patients with IPF has improved over the decades, and antifibrotic use was consistently associated with improved survival.Clinical trial registered with clinicaltrials.gov (NCT04160715).

Background: E-cigarettes are steadily gaining popularity in Korea. However, the characteristics of e-cigarette smokers, especially nicotine dependence and stress susceptibility, have not been evaluated in comparison to those of non-smokers or combustible cigarette smokers in Korea., Methods: In this study, 28,059 participants from the Korea National Health and Nutrition Examination Survey (2013-2017) were classified into the following three groups: non-smokers, smokers (current smokers and ex-smokers of combustible cigarettes only), and e-smokers (current smokers and ex-smokers of e-cigarettes regardless of combustible cigarette use)., Results: Among the participants, 16,980 (60.5%), 9,247 (33.0%), and 1,832 (6.4%) subjects were non-smokers, smokers, and e-smokers, respectively. E-smokers were younger, more educated, and had a higher household income than non-smokers or smokers. The number of e-smokers who smoked within 5 minutes of waking up (31.5% vs. 19.8%, p<0.001) and who planned to quit smoking within 6 months (39.1% vs. 35.7%, p<0.05) was greater than that of smokers. E-smokers perceived stress as "very much" (7.0% vs. 4.4%, p<0.001) and "a lot" (29.1% vs. 20.5%, p<0.001) compared to non-smokers. Suicidal ideation (6.5% vs. 4.7%, p<0.001), plans (2.4% vs. 1.3%, p<0.001), and attempts (1.1% vs. 0.5%, p<0.001) were higher in e-smokers than in non-smokers. Depressive episodes in 1 year (14.2% vs. 11.4%, p<0.05) and suicidal plans (2.4% vs. 1.8%, p<0.05) were more frequent among e-smokers than among smokers., Conclusion: E-smokers were younger, more educated, and had a higher income, but they were more dependent on nicotine and susceptible to stress than non-smokers and smokers. Smoking cessation counseling should be tailored according to the characteristics of e-smokers.

Purpose: Long-term macrolide treatment is recommended for patients with chronic obstructive pulmonary disease (COPD) with frequent exacerbations. Bronchiectasis is a common comorbid condition in patients with COPD, for which long-term azithromycin is effective in preventing exacerbation. This study aimed to compare the effect of long-term azithromycin between bronchiectasis patients with chronic airflow obstruction (CAO) and COPD patients without bronchiectasis., Patients and Methods: Patients with CAO who received azithromycin for more than 12 weeks were retrospectively identified at a single referral hospital. CAO was defined as a post-bronchodilator forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC) <0.7, and bronchiectasis was determined using computed tomography. The development of exacerbation and symptom improvement were compared between bronchiectasis patients with CAO and COPD patients without bronchiectasis., Results: A total of 59 patients (43 in bronchiectasis with CAO group vs 16 in COPD without bronchiectasis group) were included in this study. Compared to COPD patients without bronchiectasis, those in bronchiectasis with CAO group were younger, more likely to be female, and never smokers. There was no difference in the previous exacerbation history or FEV 1 between the two groups. The median duration of azithromycin treatment was 15 months (interquartile range, 8-25 months). At the 12-month follow-up, the development of ≥2 moderate or ≥1 severe exacerbations was significantly lower in bronchiectasis with CAO group than in COPD without bronchiectasis group (46.5% vs 87.5%, P = 0.005). The proportion of patients with symptom improvement determined by the COPD assessment test score was also significantly higher in bronchiectasis with CAO group than COPD without bronchiectasis group at the 12-month follow-up (68.2% vs 16.7%, P = 0.004)., Conclusion: Bronchiectasis patients with CAO could benefit more from long-term azithromycin treatment than COPD patients without bronchiectasis., Competing Interests: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. The authors report no conflicts of interest in this work., (© 2021 Choi et al.)

Background: There are limited data about the racial difference in the characteristics of chronic obstructive pulmonary disease (COPD) patients who are treated at clinics. We aimed to compare sociodemographic and clinical characteristics between US and Korean COPD patients using large-scale nationwide COPD cohorts., Methods: We used the baseline demographic and clinical data of COPD patients aged 45 years or older with at least a 10 pack-per year smoking history from the Korean COPD Subtype Study (KOCOSS, n  = 1686) cohort (2012-2018) and phase I (2008-2011) of the US Genetic Epidemiology of COPD (COPDGene) study ( n  = 4477, 3461 were non-Hispanic whites [NHW], and 1016 were African Americans [AA])., Results: Compared to NHW, AA had a significantly lower adjusted prevalence ratio (aPR) of cough >3 months (aPR: 0.67; 95% CI [confidence interval]: 0.60-0.75) and phlegm >3 months (aPR: 0.78, 95% CI: 0.70-0.86), but higher aPR of dyspnea (modified Medical Round Council scale ⩾2) (aPR: 1.22; 95% CI: 1.15-1.29), short six-minute walk distance (<350 m) (aPR: 1.98; 95% CI: 1.81-2.14), and poor quality of life (aPR: 1.10; 95% CI: 1.05-1.15). Compared to NHW, Koreans had a significantly lower aPR of cough >3 months (aPR: 0.53; 95% CI: 0.47-0.59), phlegm >3 months (aPR: 0.75; 95% CI: 0.67-0.82), dyspnea (aPR: 0.72; 95% CI: 0.66-0.79), and moderate-to-severe acute exacerbation in the previous year (aPR: 0.73; 95% CI: 0.65-0.82). NHW had the highest burden related to chronic bronchitis symptoms and cardiovascular diseases related to comorbidities., Conclusion: There are substantial differences in sociodemographic characteristics, clinical presentation, and comorbidities between COPD patients from the KOCOSS and COPDGene, which might be caused by interactions between various intrapersonal, interpersonal, and environmental factors of the ecological model. Thus, a broader and more comprehensive approach would be necessary to understand the racial differences of COPD patients., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2021.)

Background: Chronic obstructive pulmonary disease (COPD) requires careful ambulatory care. If treatment is effective, exacerbation and hospitalization can be preventable. Appropriate management is important; the disease prevalence is high, as is the demand on healthcare resources. Here, we have reported the results of nationwide quality assessment performed with the aims of improving patient management, reducing progression to severe status, and minimizing medical care expenses., Methods: The Health Insurance Review and Assessment Service (HIRA) engaged in quality assessment three times from May 2014 to April 2017. Medical care institutions were evaluated in terms of the pulmonary function test (PFT), patient revisit, and inhaled bronchodilator prescription rates., Results: The numbers of patients assessed were 141,782, 142,790, and 143,339 in years 1, 2, and 3, respectively; the numbers of medical care institutions assessed were 6,691, 6,722, and 6,470, respectively. The PFT implementation rates were 58.7%, 62.5%, and 67.9% for years 1, 2, and 3, respectively; these rates were highest for tertiary hospitals, followed by general and local hospitals, as well as primary healthcare clinics. The repeat visit rates were 85.5%, 92.1%, and 85.0% for years 1, 2, and 3, respectively; these rates were highest for general hospitals, followed by local and tertiary hospitals, and primary healthcare clinics. The inhaled bronchodilator prescription rates were 67.9%, 71.2%, and 76.9% for years 1, 2, and 3, respectively; these rates increased with increasing hospital grade., Conclusions: The PFT and inhaled bronchodilator prescription rates improved over the 3-year nationwide quality assessment period., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-905). Prof Rhee serves as an unpaid editorial board member of Journal of Thoracic Disease. The authors have no other conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Background/aims: Despite increasing awareness of the burden of chronic obstructive pulmonary disease (COPD) in women, knowledge regarding gender differences in COPD outcomes is limited. Therefore, we aimed to evaluate whether COPD outcomes, including exacerbations, lung function, and symptoms differ by gender., Methods: We recruited patients with COPD from two Korean multicenter prospective cohorts. After propensity score matching, the main outcome, the incidence of moderate or severe exacerbations was analyzed using a negative binomial regression model. We also assessed changes in lung function and symptom scores including the St. George's respiratory questionnaire for COPD (SGRQ-C), COPD assessment test (CAT), and the modified Medical Research Council (mMRC) dyspnea score., Results: After propensity score matching, 74 women and 74 men with COPD were included. The incidence rates of exacerbations in women and men were not significantly different (incidence rate ratio, 1.49; 95% confidence interval [CI], 0.88 to 2.54). There was no significant difference in the incidence rates adjusted for medication possession ratios of long-acting muscarinic antagonists, long-acting β-agonists, and inhaled corticosteroids during the follow-up period (incidence rate ratio, 1.47; 95% CI, 0.86 to 2.52). Rates of decline in post-bronchodilator forced expiratory volume in 1 second and forced vital capacity did not differ between women and men during 48 months of follow-up. The changes in scores on the SGRQ-C, CAT, and mMRC Questionnaire in women were also similar to those in men., Conclusion: We observed no gender differences in the rate of exacerbations of COPD in a prospective longitudinal study. Further studies are needed to confirm these findings in the general COPD population.

Background/aims: Many chronic obstructive pulmonary disease (COPD) patients have physical limitations. We investigated EuroQol five-dimensions five-level (EQ-5D-5L) of COPD patients to assess quality of life, and assessed indirect burden including time expenditure to visit doctor, home care rate, and caregiver related burden., Methods: We recruited 355 COPD patients according to severity of airflow limitation that severity was set at 10% mild, 40% moderate, 30% severe, and 20% very severe in two primary and 11 secondary/tertiary hospitals. Eligible patients were aged ≥ 40 years, who have been diagnosed with COPD for more than 1 year. Patients were recruited between June 2015 and October 2016., Results: The quality of life tended to decline with age, from mild to very severe impairment, as revealed by the EQ-5D-5L scores and the EQ visual analog scale. Family caregivers accompanied 22.6% of patients who visited outpatient clinics, and 25% of stage IV COPD patients. During emergency visits and hospitalization, this figure increased to > 60%. The home care rates were 28.5% for stage I patients, and 34.4, 31.8, and 52% for stage II to IV patients, respectively. The percentage of caregivers who stopped working was 13.6%. The EQ-5D index was strongly associated with the dyspnea scale (r = -0.64, p < 0.001). The average required time to see a doctor and visit the pharmacy was 154 minutes., Conclusion: In patients with COPD, the EQ-5D index decreased and disease-related home caregiving increased with airflow limitation. We considered the caregiver- related burden when making a strategy for COPD management.

Background: Metabolic syndrome (MetS) is a well-known comorbidity of chronic obstructive pulmonary disease (COPD). However, their interrelationship, particularly in early COPD, remains unclear. Therefore, we aimed to assess the prevalence and clinical characteristics of MetS in patients with early COPD, and to explore the impact of MetS on the frequency of COPD exacerbations and associated medical costs., Patients and Methods: We retrospectively enrolled 43,874 subjects from the KNHANES, including 2164 patients with early COPD (≥40 years old), recorded smoking history, and Global Initiative for Chronic Obstructive Lung Disease spirometric grade I or II, with data linked to the NHI database. We extracted and analyzed data regarding health-care utilization and medical costs for 5 years (2007 to 2012)., Results: Among 2164 patients with early COPD, the prevalence of MetS was 31.2%, and it was higher in women than in men (35.1% vs. 26.6%; P<0.001). Patients with MetS were older and had lower pulmonary function and greater number of comorbidities. The frequency of moderate-to-severe COPD exacerbations for 5 years was significantly higher in women with MetS than in those without MetS (5.8/year vs. 4.9/year; P=0.02). After adjusting for confounding factors, the risk for moderate-to-severe exacerbation was significantly greater in women with MetS (IRR, 1.17; 95% CI, 1.01 to 1.36; P=0.03). COPD exacerbations leading to hospitalization and medical expenses were also higher in women with MetS than in those without MetS., Conclusion: MetS is more prevalent in women with early COPD. MetS increased the frequency of exacerbations and the medical costs in women with early COPD., Competing Interests: The authors report no conflicts of interest in this work., (© 2019 Choi et al.)

Background: Pulmonary functions are interpreted using predicted values from reference equations that vary with ethnicity, gender, age, height, and weight. The universally used Choi's reference equations are not validated for Korean populations, and the purpose of this study was to validate them and develop new reference equations., Methods: Subjects with normal spirometry and chest radiographs, no co-morbidities, and non-smokers, from the Korean National Health and National Examination Survey (KNHANES)-VI were enrolled (n = 117). Intraclass correlation coefficient (ICC) was assessed for reliability of reference equations. New reference equations were developed using linear regression analysis. Differences between observed and predicted values were assessed to compare the reference equations from Choi's, Global Lung Function Initiative 2012, KNHANES-IV, and newly developed equations., Results: The ICC of Choi's reference equations was 0.854 (P < 0.001). The new reference equations for men were: forced vital capacity (FVC) (L) = - 4.38775 - 0.01184 × age + 0.05547 × height, forced expiratory volume - 1 second (FEV₁) (L) = - 2.40147 - 0.02134 × age + 0.04103 × height; and for women: FVC (L) = - 3.09063 + 0.003904 × age + 0.038694 × height; FEV₁ (L) = - 1.32933 - 0.00872 × age + 0.02762 × height. The differences between the predicted and observed means were largest in Choi's equations, but lowest in the new equations with highest goodness of fit., Conclusion: Because Choi's reference equations presented larger differences from the observed values, despite reliability, and the new reference equations showed better goodness of fit, we suggest the latter for Korean populations., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2019 The Korean Academy of Medical Sciences.)

Background and Objective: The Exacerbations of Chronic Obstructive Pulmonary Disease Tool-Patient-Reported Outcomes (EXACT-PRO) has been suggested as a reliable and valid measure for early assessment of COPD exacerbations and perceived recovery. However, there has been no evidence for EXACT-PRO efficacy in assessing recovery from treatment in a randomized controlled trial. The study evaluated the reliability, validity, and responsiveness of EXACT-PRO for the evaluation of the efficacy of acute treatment in patients with COPD exacerbation., Methods: In a Phase III randomized controlled study for assessing the efficacy of antibiotic treatment on COPD exacerbation, EXACT-PRO was evaluated in the responders and non-responders., Results: A total of 295 patients were analyzed (259 responders and 37 non-responders). Cronbach's α was 0.96 for EXACT total, 0.96 for the breathlessness domain, 0.89 for the cough and sputum domain, and 0.93 for the chest symptoms domain. The EXACT score correlated with the COPD assessment test (CAT) score ( r =0.8, P <0.01). A stronger decrease in the EXACT score was found in the responder group than in the non-responder group from the fifth day after treatment. The difference in the EXACT score from exacerbation onset to recovery was -6.3 in responders and -1.9 in non-responders ( P =0.01)., Conclusion: EXACT-PRO is a comprehensive and sensitive method for assessing symptomatic resolution of COPD exacerbations during treatment., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: The 2017 GOLD guidelines revised assessment of COPD by eliminating the FEV 1 criterion., Aim: First, we explored the redistribution of 2011 GOLD groups by reference to the 2017 GOLD criteria. Second, we investigated the characteristics of GOLD B patients and the natural course of GOLD B patients according to the 2017 GOLD guidelines., Methods: In total, 2,010 COPD patients in the Korean COPD Subgroup Study cohort were analyzed at baseline and 1 year after enrollment., Results: The 2011 GOLD C patients were redistributed to the 2017 A (64.5%) and C (35.4%) groups. The 2011 GOLD D patients were redistributed to the 2017 B (61.6%) and D (38.6%) groups. The GOLD B patients constituted 62.7% of all patients according to the 2017 classification. Such patients exhibited higher % predicted FEV 1 values, longer six-minute walk distances, fewer symptoms, and lower inflammatory marker levels than GOLD D patients. Most GOLD B patients remained in that group (69.1%), but 13.8% progressed to group D at 1-year follow-up. The factors associated with progression from GOLD B to GOLD D were older age, higher modified Medical Research Council (mMRC) and St George's Respiratory Questionnaire (SGRQ) symptom scores, and a lower % predicted FEV 1 value., Conclusion: Severe symptoms, poorer health status, and greater airflow limitation increased patients' risk of exacerbation and progression from group B to group D when the 2017 GOLD criteria were applied., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background and Purpose: Chronic cough can be a dominant symptom of chronic obstructive pulmonary disease (COPD), although its clinical impact remains unclear. The aim of our study was to identify phenotypic differences according to the presence of chronic cough or sputum and evaluate the impact of chronic cough on the risk of acute exacerbation of COPD (AECOPD)., Methods: In a nationwide COPD cohort including 1,613 COPD patients, patients with chronic cough only, those with sputum only, those with chronic bronchitis (CB), and those without cough and sputum were compared with regard to dyspnea, lung function, quality of life (QoL), and risk of AECOPD., Results: The rates of chronic cough, chronic sputum, and both were 23.4%, 32.4%, and 18.2%, respectively. Compared with patients without chronic cough, those with chronic cough exhibited a lower forced expiratory volume in 1 second (% predicted) and diffusing capacity of the lungs for carbon monoxide (% predicted), more frequent AECOPD, more severe dyspnea, and worse QoL. Pulmonary function, dyspnea severity, and QoL worsened in the following order: without cough or sputum, with sputum only, with cough only, and with CB. Multivariate analyses revealed chronic cough as an independent risk factor for a lower lung function, more severe dyspnea, and a poor QoL. Moreover, the risk of future AECOPD was significantly associated with chronic cough (odds ratio 1.56, 95% CI 1.08-2.24), but not with chronic sputum., Conclusion: Our results suggest that chronic cough should be considered as an important phenotype during the determination of high-risk groups of COPD patients., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Gelsolin is an actin binding protein present in blood plasma and in cytoplasm of cells including macrophages. Gelsolin has important functions in cell cycle regulation, apoptotic regulation, and morphogenesis. Even though bone marrow macrophages and serum factors are critical for regulating erythropoiesis, the role of gelsolin on human erythroblasts has not been studied. Here, we investigated the effects of human recombinant plasma gelsolin (pGSN) on human immature erythroblasts. CD34+ cells isolated from cord blood were differentiated into erythroid cells in serum-free medium. When pGSN was applied to the culture medium, it accelerated basophilic and polychromatic erythroblast maturation and increased the enucleation rate with highly expressed erythropoiesis-related mRNAs. Also, pGSN was effective in reducing dysplastic changes caused by vincristine, suggesting its role in cell cycle progression at G2/M checkpoints. Also, pGSN activated caspase-3 during maturation stages in which caspase-3 functions as a non-apoptotic maturational signal or a pro-apoptotic signal depending on maturation stages. Our results suggest that pGSN has a pivotal role in maturation of erythroblasts and this factor might be one of the way how bone marrow macrophages and previously unknown serum factors work to control erythropoiesis. pGSN might be used as additive for in vitro production of erythrocytes., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: In South Korea, chronic obstructive pulmonary disease (COPD) is one of the ten leading causes of death. COPD exacerbations are significantly associated with mortality in COPD patients. This study was conducted to investigate the epidemiology of COPD in South Korea, specifically the clinical characteristics of South Korean COPD patients, the COPD exacerbation rate and the risk factors associated with COPD exacerbations., Methods: This study covers a 2-year interval. One year was data collected retrospectively and the second year was prospectively obtained data., Results: A total of 1,114 subjects were enrolled in the study. These subjects were observed for a period of 1 year from the enrollment, and a total of 920 subjects completed the study. A total of 1,357 COPD exacerbations occurred in 711 subjects (63.8%) out of the total of 1,114 subjects during the study period of 2 years. Multivariate logistic regression results showed that if patients had had a pneumonia before the retrospective year of analysis, they had a 18 times greater chance of having an exacerbation during the prospective year when other variables were controlled. Also, the subjects who had a history of two or more exacerbations during the retrospective year were approximately 6 times more likely to experience the COPD exacerbation compared to those who did not., Conclusions: This study examined the demographic and clinical characteristics of South Korean COPD patients and found that a history of pneumonia and two or more occurrences of exacerbation within 1 year was significantly associated with a higher rate of COPD exacerbation.

Background: Spirometric measurements of pulmonary function are important in diagnosing and determining the severity of chronic obstructive pulmonary disease (COPD). We performed this study to determine whether candidate genes identified in genome-wide association studies of spirometric measurements were associated with COPD and if they interacted with smoking intensity., Methods: The current analysis included 1,000 COPD subjects and 1,000 controls recruited from 24 hospital-based pulmonary clinics. Thirteen SNPs, chosen based on genome-wide association studies of spirometric measurements in the Korean population cohorts, were genotyped. Genetic association tests were performed, adjusting for age, sex, and smoking intensity, using models including a SNP-by-smoking interaction term., Results: PID1 and FAM13A were significantly associated with COPD susceptibility. There were also significant interactions between SNPs in ACN9 and FAM13A and smoking pack-years, and an association of ACN9 with COPD in the lowest smoking tertile. The risk allele of FAM13A was associated with increased expression of FAM13A in the lung., Conclusions: We have validated associations of FAM13A and PID1 with COPD. ACN9 showed significant interaction with smoking and is a potential candidate gene for COPD. Significant associations of genetic variants of FAM13A with gene expression levels suggest that the associated loci may act as genetic regulatory elements for FAM13A gene expression.

Reticulocytes contain both RNA and micro-organelles and represent the last stage of erythropoiesis before full maturation to red blood cells (RBCs). Even though there is continuing synthesis of hemoglobin and membrane-bound proteins in reticulocytes, the small amount of RNA that they contain has been regarded as non-functional residual material. Here we show that this residual RNA is both functional and essential for further reticulocyte maturation. Reticulocytes from which the remnant RNA had been removed by exposure to RNase did not survive or mature into RBCs in either humans or mice. Conversely, reticulocytes treated with an RNase Inhibitor were able to form normal biconcave cells. Similarly, poor survival was also seen in reticulocytes in which protein synthesis had been blocked. To identify the signaling pathways involved we isolated RNAs in reticulocytes versus those present in fully matured erythroblasts cultured from hematopoietic stem cells. RNAs found in erythroblasts were related to exocytosis, metabolism, and signal transduction all of which are critical for maturation through reticulocyte and into a fully mature, biconcave erythrocyte. Our results suggest that the mRNA in reticulocytes has to be translated into novel proteins that act to preserve mitochondria and maintain cell membrane integrity as reticulocytes mature. These results enhance our understanding of the final stage of erythropoiesis and may clarify why in vitro-generated reticulocytes for transfusion purposes survive poorly., (Copyright © 2014 Elsevier Inc. All rights reserved.)

In vitro erythropoiesis has been studied extensively for its application in the manufacture of transfusable erythrocytes. Unfortunately, culture conditions have not been as effective as in vivo growth conditions, where bone marrow macrophages are known to be a key regulator of erythropoiesis. This study focused on the fact that some erythroblasts are detached from macrophages and only contact other erythroblasts. We hypothesized that additional factors regulate erythroblasts, likely through either physical contact or secreted factors. To further elucidate these critical factors, human erythroblasts derived from cord blood were cultured at high density to mimic marrow conditions. This growth condition resulted in a significantly increased erythroid enucleation rate and viability. We found several novel contact-related signals in erythroblasts: intercellular adhesion molecule-4 (ICAM-4) and deleted in liver cancer-1 (DLC-1). DLC-1, a Rho-GTPase-activating protein, has not previously been reported in erythroid cells, but its interaction with ICAM-4 was demonstrated here. We further confirmed the presence of a secreted form of human ICAM-4 for the first time. When soluble ICAM-4 was added to media, cell viability and enucleation increased with decreased nuclear dysplasia, suggesting that ICAM-4 is a key factor in contact between cells. These results highlight potential new mechanisms for autonomous control of erythropoiesis. The application of these procedures to erythrocyte manufacturing could enhance in vitro erythrocyte production for clinical use., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Purpose: The reported actual compliance for severe sepsis bundles was very low, suggesting the presence of barriers to their implementation. The purpose of this study was to assess the influence of full-time intensivist and nurse-to-patient ratio in Korean intensive care units (ICUs) on the implementation of the severe sepsis bundles and clinical outcome., Materials and Methods: A total of 251 patients with severe sepsis were enrolled from 28 adult ICUs during the July, 2009. We recorded the organizational characteristics of ICUs, patients' characteristics and clinical outcomes, and the compliance for severe sepsis bundles., Results: Complete compliance with the resuscitation bundle and totally complete compliance with all element targets for resuscitation and management bundles were significantly higher in the ICU with full-time intensivist and a nurse-to-patient ratio of 1:2 (P < .05). The hazard ratio (HR) for hospital mortality was independently reduced by the presence of full-time intensivist (HR, 0.456; 95% confidence interval, 0.223-0.932), and a nurse-to-patient ratio of 1:2 was independently associated with a lower 28-day mortality (HR, 0.459; 95% confidence interval, 0.211-0.998)., Conclusions: The full-time intensivist and the nurse-to-patient ratio had a substantial influence on the implementation of severe sepsis bundles and the mortalities of patients with severe sepsis., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Although it was thought that platelets did not play a significant role in the pathogenesis of venous thromboembolism (VTE), several studies demonstrated that a marked activation of platelets occurs in patients with VTE. We carried out a case-control study to investigate the effect of the T744C P2RY12 polymorphism on the risk of VTE in the Korean population. We enrolled 154 consecutive patients with VTE and 415 healthy controls. Genotype frequencies for patients with TT, TC, and CC were 71.4%, 24.7%, and 3.9% and in the controls, 68.2%, 30.1%, and 1.7%, respectively. T744C P2RY12 polymorphism did not significantly affect the risk of VTE. Our study shows that T744C P2RY12 polymorphism did not significantly affect the risk of VTE in the Korean population.

Objectives: We assessed the incidence and clinical characteristics of acute kidney injury (AKI) in critically ill patients infected with pandemic influenza A (H1N1) and its effect on clinical outcomes., Methods: We conducted a multicenter, retrospective, observational study of patients with pandemic H1N1-related critical illness admitted to intensive care units (ICUs) of 28 tertiary or referral hospitals in South Korea between September 1, 2009, and February 28, 2010. Outcomes were AKI within 72 hours after ICU admission and 30-day mortality. Acute kidney injury was defined according to the Risk, Injury, Failure, Loss, and End-stage renal failure criteria., Results: Of the 221 patients, 50 (22.6%) developed AKI within 72 hours after ICU admission. Independent risk factors for AKI were age (odds ratio [OR], 1.05; P = .003), chronic kidney disease (OR, 14.82; P = .004), and Sequential Organ Failure Assessment score (OR, 1.45; P < .001). Age (OR, 1.04; P = .003), Sequential Organ Failure Assessment score (OR, 1.28; P = .012), state of immune suppression (OR, 4.09; P = .01), mechanical ventilation (OR, 18.24; P = .001), corticosteroid use (OR, 3.09; P = .007), and AKI (OR, 2.86; P = .035) were significantly associated with 30-day mortality., Conclusions: A significant number of patients with H1N1-related critical illness developed AKI within 72 hours of ICU admission, and this early development of AKI was associated with 30-day mortality., (Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.)

Platelet aggregation plays crucial roles in the formation of hemostatic plugs and thrombosis. Although it was recently shown that canonical Wnt signaling negatively regulates platelet aggregation, the role of non-canonical Wnt signaling remains unknown. Here, we observed that Wnt5a, one of the non-canonical Wnts, positively regulated platelet aggregation. Platelet aggregation was potentiated by the addition of Wnt5a to collagen-or U46619-induced rat platelet rich plasma (PRP). Treatment with Wnt5a to U46619-stimulated PRP resulted in an increase in the level of phosphorylated Akt, whereas phosphorylation of PKCδ and JNK1 was unaffected. In addition, inhibition of PI3K blocked the potentiating effect of Wnt5a. Taken together, these results suggest that Wnt5a potentiates U46619-induced platelet aggregation via the PI3K/Akt pathway.

Background and Objective: Although there is controversy regarding the benefit of low-dose corticosteroid therapy in patients with septic shock, the Surviving Sepsis Campaign has advocated that low-dose intravenous hydrocortisone be used to treat adult septic shock patients. This study investigated the effect of the duration of a stress dose of hydrocortisone on survival of septic shock patients with relative adrenal insufficiency., Methods: One hundred and thirty consecutive patients who met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock were included in the study. An additional inclusion criterion was vasopressor support after fluid resuscitation. The primary end-point was 28-day mortality, and the secondary end-points were shock reversal and mortality in the intensive care unit and hospital. All eligible patients were prospectively randomized to receive hydrocortisone treatment for 3 or 7days. Hydrocortisone treatment was started at a dose of 50mg every 6h., Results: Baseline data at recruitment did not differ between the two groups. After 28days, mortality did not differ between the 3- and 7-day treatment groups (33.8% vs 36.9%, P=0.629). Mortality rates in the intensive care unit and hospital did not differ significantly between the two groups. The median time to withdrawal of vasopressor therapy was 5.0days in the 3-day treatment group and 6.4days in the 7-day treatment group (P=0.102)., Conclusions: This pilot study showed that in patients with septic shock and relative adrenal insufficiency, 28-day mortality did not differ between those treated with low-dose hydrocortisone for 3 or 7days., (© 2011 The Authors. Respirology © 2011 Asian Pacific Society of Respirology.)

The roots of two Paeoniaceae family members have long been used as traditional medicines in Korea, China, and Japan. Dry roots of Paeonia lactiflora and dry root bark of P. suffruticosa are used under the traditional names of Paeoniae Radix and Moutan Cortex, respectively. Both Paeoniae Radix and Moutan Cortex have been used as remedies for cardiovascular diseases, for improving blood circulation, or for other uses. It was postulated that both plants may contain common active constituents that contribute to inhibiting blood coagulation and/or platelet aggregation. Eighteen compounds, which have been reported to be present in both plant medicines, were evaluated for their effects on platelet aggregation and blood coagulation. Paeonol (5), paeoniflorin (9), benzoylpaeoniflorin (11), and benzoyloxypaeoniflorin (12) were found to be the major common active constituents and they would collectively contribute to improving blood circulation through their inhibitory effects on both platelet aggregation and blood coagulation. In addition, methylgallate (4), (+)-catechin (7), paeoniflorigenone (8), galloylpaeoniflorin (13), and daucosterol (16) may also take part in improving blood circulation by inhibiting ether platelet aggregation and/or blood coagulation.

Seven ginsenosides, namely Rg6 (1), F4 (2), Rk3 (3), Rh4 (4), Rs3 (5), Rs4 (6) and Rs5 (7) isolated from processed ginseng were evaluated for their effects on platelet aggregation induced by adenosine diphosphate (ADP), collagen, arachidonic acid (AA) and U46619 (thromboxane A2 mimetic drug). Ginsenosides Rg6, F4 and Rk3 showed inhibitory activity (IC50 = 76 microM, 114 microM and 128 microM, respectively) on AA-induced platelet aggregation. The corresponding IC50 values were comparable to that of acetylsalicylic acid (ASA) (63 microM). Compared to ASA (IC50 = 468 microM) ginsenosides Rg6, F4, Rk3 and Rh4 were found to be more inhibitive (IC50 = 286 microM, 87 microM, 187 microM and 119 microM, respectively) against U46619-induced aggregation. On the other hand, most of the ginsenosides (Rg6, F4, Rh4, Rs3, Rs5) showed negligible effects on ADP and collagen-induced platelet aggregation. The acetylated ginsenosides (Rs3, Rs4 and Rs5) had only mild effects on aggregation induced by four stimulators.

Platelets are highly reactive components of the circulatory system. The cytoskeleton of a platelet is an important structure for platelet aggregation as stimulated by several agonists. An anticancer agent, taxol, has been suggested to exert platelet anti-aggregating activity by stabilizing microtubules during the aggregation process. An activity-guided fractionation was performed with a methanol extract of the leaves and twigs of Taxus cuspidata to isolate taxanes with platelet anti-aggregating effects. Compounds 1 to 7 - taxinine (1), taxinine A (2), taxinine B (3), 2-deacetoxytaxinine B (4), taxacin (5), taxchinin B (6), and taxol (7) - were obtained as the antiplatelet components of this plant. These taxane compounds present the possibility of securing new antiplatelet compounds which differ from currently available antiplatelet agents in chemical structure and possibly in mechanisms of action. All compounds showed stronger inhibitory effects than acetylsalicylic acid (ASA) on platelet aggregation induced by arachidonic acid (AA) (IC(50): 14.4, 64.5, 35.5, 16.0, 21.9, 28.6 and 48.2 versus 63.0microM) or U46619 (IC(50): 34.8, 24.9, 36.2, 35.0, 46.9, 71.9 and 68.7 versus 340microM). Compounds 1, 3, 4 and 5, with a cinnamoyl group at the C(5) position, showed strong inhibitory effects against AA-induced aggregation compared to compound 2 (with an -OH group at C(5)) or compounds with an oxetane ring at C(4),(5), such as compounds 6 and 7. All of the seven compounds were 5-13-fold more strongly inhibitory than ASA against U46619-induced aggregation., (Copyright 2010 Elsevier Ltd. All rights reserved.)

In spite of their potential as biologically active compounds, the high molecular mass and viscous natures of fucoidans have hampered their applications especially as a therapeutic agent. Herein the fucoidan-degrading enzyme activities were partially purified from the cultured cells of Sphingomonas paucimobilis PF-1 mainly by ammonium sulfate precipitation. This enzyme preparation degraded fucoidans from the Korean Undaria pinnatifida sporophyll into several low-molecular weight fuco-oligosaccharides (LMFOs) with less than 3,749 Da. The FTIR spectra of intact fucoidan and mixture of LMFOs (1,389-3,749 Da) showed no significant structural difference except for about 10% reduced level of sulfate esters in LMFOs. The LMFOs have exerted strong anticoagulating activities at which the activated partial thromboplastin time (APTT) and thrombin time (TT) were significantly prolonged, although 3 approximately 20 times weaker activities were observed than those of intact fucoidan. In addition, unlike intact fucoidan, LMFOs did not affect significantly to the prothrombin time (PT). These results suggest that the partially purified fucoidan-degrading enzyme preparation is valuable for the production of fuco-oligosaccharides having anticoagulating activities, and that the molecular weight and/or sulfate content of the fucoidan from the Korean Undaria pinnatifida sporophyll could be important factors for its anticoagulating activity.

Four dammarane glycosides, namely ginsenosides Rk1 (1), Rg5 (2), 20(S)-Rg3 (3), and 20(R)-Rg3 (4), isolated from a new processed ginseng, were evaluated for their inhibitory activity against platelet aggregation induced by adenosine diphosphate (ADP), collagen, arachidonic acid (AA) and U46619 (thromboxane A2 mimetic agent). Ginsenoside Rk1 and Rg5 inhibited AA-induced platelet aggregation in a dose dependent manner. Their activity against AA-induced platelet aggregation were found to be 8-22 fold higher than that of a known antiplatelet drug acetylsalicylic acid (ASA). They also inhibited U46619-induced platelet aggregation. Ginsenoside 20(S)-Rg3 and 20(R)-Rg3 showed mild inhibitory activity against AA and U46619-induced aggregation.

Introduction: A previous report assigned 35 healthy Koreans into five groups (groups A to E) based on their platelet responsiveness to catecholamines (CA). The present work aimed to elucidate the possible mechanism of heterogeneous responsiveness to CA in normal subjects., Materials and Methods: The degrees of aggregation in platelet rich plasma (PRP) were measured with a turbidimetric method. The expression of platelet glycoprotein and activation maker was analyzed with flow cytometric method in whole blood., Results and Conclusions: The degrees of aggregation in response to other aggregation inducing agents (AA, ADP, and U46619) were significantly lower in platelets hyporesponsive to CA. The flow cytometric analysis showed that GPIIb, GPIIIa and GPIIb/IIIa expressions were 20.1%, 25.7%, and 38.2%, respectively, higher in the CA-responsive group than in the CA-hyporesponsive group when the groups were in a TRAP activated state, while no differences were observed between the two groups when in a resting state.

Lichen species were collected from King George Island (Antarctica) and were screened for their immunomodulatory effect. Among the lichens tested, the methanol extract (CR-ME) of Caloplaca regalis showed the highest nitric oxide (NO) production in murine peritoneal macrophages. Therefore, this study further examined the ability of C. regalis to induce secretory and cellular responses in macrophages. Macrophages were treated with various concentrations of CR-ME for 18 h. The CR-ME treatment induced tumoricidal activity and increased the production of tumor necrosis factor-alpha (TNF-alpha) and nitric oxide by macrophages. However, CR-ME had a little effect on the levels of reactive oxygen species, interleukin-1 and IFN-gamma in CR-ME-treated macrophages. The CR-ME-induced tumoricidal activity was partially abrogated by a NO inhibitor and the anti-TNF-alpha antibody. Thus, the tumoricidal effect of CR-ME appeared to be mainly mediated by NO and TNF-alpha production from macrophages. Treating the macrophages with a p38 mitogen-activated protein kinase (MAPK) inhibitor partially blocked the tumoricidal activation induced by CR-ME, whereas inhibitors of the other kinases did not have an inhibitory effect. These results suggest that CR-ME induces the tumoricidal activity via the p38 MAPK-dependent pathway. Furthermore, electrophoretic mobility shift assay analyses revealed that the CR-ME treatment induced the activation of the NF-kappaB transcription factor. Overall, these results indicate that the tumoricidal activity induced by CR-ME is mainly due to TNF-alpha and NO production, and the activation of macrophage by CR-ME is mediated probably via the p38 MAPK and NF-kappaB pathway. Our results may also provide some leads in the development of new immunomodulating drugs.

Introduction: In acute respiratory distress syndrome (ARDS), adequate positive end-expiratory pressure (PEEP) may decrease ventilator-induced lung injury by minimising overinflation and cyclic recruitment-derecruitment of the lung. We evaluated whether setting the PEEP using decremental PEEP titration after an alveolar recruitment manoeuvre (ARM) affects the clinical outcome in patients with ARDS., Methods: Fifty-seven patients with early ARDS were randomly assigned to a group given decremental PEEP titration following ARM or a table-based PEEP (control) group. PEEP and inspired fraction of oxygen (FiO2) in the control group were set according to the table-based combinations of FiO2 and PEEP of the ARDS network, by which we aimed to achieve a PEEP level compatible with an oxygenation target. In the decremental PEEP titration group, the oxygen saturation and static compliance were monitored as the patients performed the ARM along with the extended sigh method, which is designed to gradually apply and withdraw a high distending pressure over a prolonged period, and the decremental titration of PEEP., Results: The baseline characteristics did not differ significantly between the control and decremental PEEP titration groups. Initial oxygenation improved more in the decremental PEEP titration group than in the control group. However, dynamic compliance, tidal volume and PEEP were similar in the two groups during the first week. The duration of use of paralysing or sedative agents, mechanical ventilation, stay in the intensive care unit and mortality at 28 days did not differ significantly between the decremental PEEP titration and control groups., Conclusions: The daily decremental PEEP titration after ARM showed only initial oxygenation improvement compared with the table-based PEEP method. Respiratory mechanics and patient outcomes did not differ between the decremental PEEP titration and control groups., Trial Registration: ClinicalTrials.gov identifier: ISRCTN79027921.

A methanol extract of Sophora japonica was subjected to anti-platelet activity guided fractionation affording the isolation of four flavonoids and six flavonoid-glycosides: biochanin A (1), irisolidone (2), genistein (3), sissotrin (4), sophorabioside (5), genistin (6), tectoridin (7), apigenin (8), quercitrin (9), and rutin (10). The structure of each compound was determined by a variety of spectroscopic methods. Among the compounds, 1, 3, and 7 showed approximately 2.5-6.5 fold greater inhibitory effects on arachidonic acid (AA) and U46619 induced platelet aggregation (IC50: 19.9 and 99.8 microM; 20.3 and 53.8 microM; 25.9 and 123.4 microM, respectively) than acetylsalicylic acid (ASA, IC50: 63.0 and 350.0 microM). Compound 2 was an approximately 22-40 fold stronger inhibitor than ASA on AA and U46619 induced aggregation (IC50: 1.6 and 15.6 microM, respectively).

This study examined the effects of red ginseng acidic polysaccharide (RGAP) on macrophage-mediated cytotoxicity towards murine melanoma B16 cells. RGAP alone had no effect on killing of tumor cells. RGAP treatment increased the production of interleukin-1 (IL-1), IL-6, and nitric oxide (NO) by macrophages, whereas tumor necrosis factor (TNF-alpha) and reactive oxygen species (ROS) production were not changed by RGAP. However, treatment of macrophages with a combination of RGAP and recombinant interferon-gamma (rIFN-gamma) enhanced killing of tumor cells. In addition, the combination treatment showed marked cooperative induction of IL-1, IL-6, TNF-alpha, and NO production. Electrophoretic mobility shift assay analysis revealed that treatment of macrophages with RGAP plus rIFN-gamma induced the activation of the nuclear factor-kappa B (NF-kappaB) transcription factor. In agreement with this, the combination treatment resulted in increased NF-kappaB-p65 expression. The present results demonstrate synergistic effects on macrophage function of RGAP in combination with rIFN-gamma, and suggest that NF-kappaB plays an important role in mediating these effects. These data also support the development of clinical studies of this combination.

Overexpression of the gene for heme oxygenase (HO)-1 leads to a reduction in pressor responsiveness to angiotensin II (Ang II) in experimental animals. Using rat vascular smooth muscle cells (VSMCs), we tested whether YS 49 [1-(alpha-naphtylmethyl)-6,7-dihydroxy-1,2,3,4-tetrahydroisoquinoline] inhibits Ang II-stimulated proliferation of VSMCs via induction of HO-1. YS 49 induced HO-1 protein production in a dose-and time-dependent manner in VSMCs. Treatment with YS 49 significantly and dose-dependently inhibited Ang II-induced VSMC proliferation, ROS production, and phosphorylation of JNK, but not P38 MAP kinase or ERK1/2. The antiproliferation effect of YS 49 was reversed by pretreatment with the HO-1 inhibitor zinc protoporphyrin IX (ZnPPIX), or with hemoglobin, a carbon monoxide (CO) scavenger. Similarly, VSMC proliferation, ROS production and phosphorylation of JNK by Ang II were significantly inhibited in VSMCs transfected with the HO-1 gene. Thus, HO-1 and the HO-1 product CO play, at least in part, a crucial role in Ang II-stimulated VSMC proliferation through the regulation of ROS production and JNK phosphorylation. Therefore, YS 49 has potential as a therapeutic strategy for the pathogenesis of Ang II-related vascular diseases such as hypertension and atherosclerosis, via the induction of HO-1 gene activity.

Activation of the inducible nitric oxide synthase (iNOS) pathway contributes to inflammation-induced osteoporosis by suppressing bone formation and causing osteoblast apoptosis. We investigated the mechanism of action by which YS-51S, a synthetic isoquinoline alkaloid, inhibits iNOS expression and nitric oxide (NO) production in ROS 17/28 osteoblast cells activated with the mixture of TNF-alpha, IFN-gamma and LPS (MIX). YS-51S, concentration- and time-dependently, increased heme oxygenase (HO-1) expression. Treatment with YS-51S 1 h prior to MIX significantly reduced MIX-induced NO production and iNOS expression with the IC50 to NO production of 47+/-3.3 microM. Electrophoretic mobility shift assay (EMSA) and western blot analysis showed that YS-51S inhibited MIX-mediated activation and translocation of NF-kappaB to nucleus by suppressing the degradation of its inhibitory protein IkappaBalpha in cytoplasm. YS-51S also reduced NF-kappaB-luciferase activity. In addition, an HO-1 inhibitor ZnPPIX, antagonized the inhibitory effect of YS-51S on iNOS expression and DNA strand break induced by MIX, indicating prevention of NO production by YS-51S is associated with HO-1 activity. Moreover, YS-51S inhibited the oxidation of cytochrome c(2+) by peroxynitrite (PN). Our results indicated that YS-51S may be beneficial in NO-mediated inflammatory conditions such as rheumatoid arthritis by alleviating iNOS expression and NO-mediated cell death of osteoblast with 1) inducing HO-1 expression, 2) interfering the activation of NF-kappaB and 3) quenching of PN.

Oxidative stress plays an important role in the pathophysiology of several vascular diseases such as atherosclerosis, and great attention has been placed on the protective role of heme oxygenase-1 (HO-1) for vasculature against oxidant-induced injury. We tested whether the protective effects of YS 51, 1-(beta-naphtyl-methyl)-6,7-dihydroxy-1,2,3,4,-tetrahydroisoquinoline, against hydrogen peroxide (H2O2)-induced cell injury is associated with HO-1 activity in bovine aortic endothelial cells (BAEC). YS 51 increased HO-1 expression and activity in concentration-dependent manners (10-100 microM) and time-dependent manners (1, 3, 6, 18 h), which were correlated well with its protective effect against H2O2-induced injury. Zinc protoporphyrin IX (ZnPP IX), a HO inhibitor, significantly inhibited the effect of YS 51 (50 microM). In contrast, [Ru(CO)3(Cl)2]2 (CORM-2, a CO releasing molecule) but not bilirubin protected against H2O2-induced injury. Oxyhemoglobin (HbO2) used as a CO scavenger significantly inhibited the protective effect of both YS 51 and CORM-2. Furthermore, both YS 51 and CORM-2 significantly reduced H2O2-induced intracellular reactive oxygen species (ROS) production; however, this was counteracted by ZnPP IX, HbO2 and deferoxamine. We found evidence for the involvement of PI3/Akt kinase and ERK1/2 pathways in HO-1 induction by YS-51. Taken together, we conclude that CO is, at least, responsible for the YS 51-mediated protective action of endothelial cells against oxidant stress via HO-1 gene induction, involving the activation of the PI3/Akt and ERK1/2 kinase pathways. Thus, YS 51 may be useful in oxidative stress-induced vascular disorders.

The magnesium (Mg) and manganese (Mn) were evaluated for its effectiveness as an immunomodulator in rats. The treatments were as follows: Group 1, AIN-93M diet (0.05% Mg, 0.001% Mn); Group 2, high-dose Mg (0.1% Mg, 0.001% Mn); and Group 3, high dose Mn (0.05% Mg, 0.01% Mn) (n-12/group). After 12 weeks of supplementation, rats were sacrificed to assess the effect on a range of innate responses (tumoricidal activity, oxidative burst and nitric oxide) and the mitogen-stimulated lymphoproliferative response. Immune function was significantly affected in both the high dose Mg and the Mn group. Lymphocyte proliferative responses and NK cell activity were measured in pooled spleen from each group. The mitogen response of lymphocytes to LPS in the spleen was significantly reduced in high dose Mg-treated groups, whereas the response to ConA was not affected in both high dose minerals-treated groups. The reactive oxygen species level of macrophages was decreased in both groups. These effects were more pronounced in high dose Mg-treated group. Nitric oxide production was also decreased in high dose minerals-treated group. In addition, tumoricidal activities of splenic NK cell and peritoneal macrophage in mineral exposed rats were significantly increased. Moreover, percent death of macrophage was reduced in two groups receiving high dose mineral supplements. Taken together, the present data suggest that high dose trace min erals exert a differential effect on the function of immune cells.

An aryltetralin lactone, (-)-(1S,2R,3R)-1-(3',4'-methylenedioxyphenyl)-3-(hydroxymethyl)-6,7-dimethoxy-1,2,3,4-tetrahydronaphthalene-2-carboxylic acid lactone, was isolated from the methanol extract of the aerial parts of Bupleurum falcatum and named bupleurumin. The structure of the compound was determined on the basis of chemical and spectroscopic methods, including two-dimensional NMR spectrometry (e.g., 1H- and 13C-NMR, homo- and heteronuclear COSY, HMBC). Bupleurumin showed an 8-fold potent inhibitory effect (IC50: 47.5 uM) compared to that of acetylsalicylic acid (ASA, IC50 : 420 uM) on collagen induced platelet aggregation and comparable effects as ASA on arachidonic acid-induced platelet aggregation.