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As the burden of tuberculosis (TB) in South Korea decreases while that of malignancy increases with an aging society, the composition of etiology for pleural effusion is changing. The aim of this study was to investigate the diagnostic value of adenosine deaminase (ADA) for diagnosis of tuberculous pleural effusion (TPE) in this circumstance. Medical records of patients who underwent medical thoracoscopy from May 2015 to September 2020 in Incheon St. Mary Hospital, Korea were retrospectively reviewed. TPE was diagnosed if one of the following criteria was met: (1) granuloma in pleura, (2) positive TB polymerase chain reaction or culture in pleural fluid or tissue with non-specific pathologic findings in pleura, or (3) bacteriologically confirmed pulmonary TB with non-specific pathologic findings in pleura. A total of 292 patients, including 156 with malignant pleural effusion (MPE), 52 with TPE, and 84 with other benign effusion, were analyzed. Among 206 patients with lymphocyte dominant pleural effusion, the area under receiver characteristic curve of ADA for diagnosis of TPE was 0.971. The sensitivity and specificity of a current cutoff value of 40 IU/L were 1.00 and 0.61, respectively, whereas those of a raised cutoff value of 70 IU/L were 0.93 and 0.93, respectively. Among 54 patients with ADA levels of 40–70 IU/L, 30 (55.6%) patients were diagnosed as MPE, 21 (38.9%) as other benign effusion, and only 3 (5.6%) as TPE. Caution is needed in clinical diagnosis of TPE with current ADA cutoff value in countries with decreasing TB incidence, due to many false positive cases.

Background: Recent advances in diagnosis and treatment have improved long-term outcomes in cancer patients. As a result, the requirement for a rapid response team (RRT) for cancer patients is also increasing. This study aimed to analyze utilization of an RRT and the associations between related factors and mortality in a population of cancer patients. Methods: This retrospective cohort study included hospitalized patients at a single academic medical center in Seoul, Korea, who required RRT activation during a 6-year period from June 2013 to December 2018. Results: Overall, 164 of the 457 patients who met the above criteria were cancer patients, and they had a significantly higher Charlson comorbidity score than the non-cancer patients (5.0 vs. 7.0, P

The purpose of this study was to evaluate whether obstructive sleep apnea (OSA)-related chronic intermittent hypoxia (CIH) influences lung cancer progression and to elucidate the associated mechanisms in a mouse model of lung cancer. C57/BL6 mice in a CIH group were exposed to intermittent hypoxia for two weeks after tumor induction and compared with control mice (room air). Hypoxia inducible factor 1α (HIF-1α), vascular endothelial growth factor (VEGF) and metastasis-related matrix metalloproteinases (MMP) were measured. The expression levels of several hypoxia-related pathway proteins including HIF-1α, Wnt/ß-catenin, the nuclear factor erythroid 2-related factor 2 (Nrf2) and mammalian target of rapamycin-ERK were measured by western blot. The number (P

Purpose: Obstructive sleep apnea (OSA) is known to be associated with upper airway collapse during sleep. However, OSA has also been suggested to have effects on the lower airway. This study examined the association between pulmonary function test (PFT) results and OSA according to the severity of OSA and the presence of obesity. Changes in PFT results with body position (sitting vs. supine) were also analyzed. Methods: A total of 46 patients who were diagnosed with OSA were included in this study. Patients were grouped according to the severity of OSA and the presence of obesity. Results: Obese, severe OSA patients tended to show poorer pulmonary function than non-obese, mild-to-moderate OSA patients. Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC; sitting), peak expiratory flow (PEF; sitting), and forced expiratory flow during the middle half of the FVC (FEF25-75; supine) were significantly lower in the severe OSA group than the mild-to-moderate OSA group (P=0.020, P=0.044, and P=0.042, respectively). Positional change from sitting to the supine position significantly reduced pulmonary function in the total OSA patient population. The effect of body position on PFT results was greater in non-obese, mild-to-moderate OSA patients. FEF25-75 in the sitting position was still significantly related to the apnea-hypopnea index in OSA patients after adjusting for other factors (P=0.048). Conclusions: This study indicated that relationships exist between lower airway function, body position, and OSA. The PFT is a simple test that can provide useful information about the upper and lower airways in OSA patients.

Background Frozen sections prepared during medical thoracoscopy (MT) have precise diagnostic ability in pleural pathology and may assist in decision-making before pleurodesis. The present study evaluated the diagnostic sensitivity of frozen sections from flex-rigid MT, and further evaluated clinical parameters for their association with a discrepancy between frozen sections and permanent paraffin sections. Methods This retrospective study evaluated 172 patients who underwent flex-rigid MT between February 2017 and November 2019 at Incheon Saint Mary's Hospital. Results Of the 172 patients, 85 were pathologically diagnosed with malignancy based on permanent paraffin sections. An accurate diagnosis by fresh frozen section was feasible in 88.2% of the cases compared to the permanent paraffin sections. Among the 85 patients, 75 had malignancies in frozen sections, while 10 patients showed otherwise. In the 85 malignant cases, age, sex, the volume of effusion, thoracoscopic findings, as well as the final pathological diagnosis (lung vs. non-lung origin) were included in univariate analysis for an association with non-malignant frozen section results. High adhesion grade and malignancy other than lung cancer were significant factors associated with frozen section negative cases in a multivariable analysis. Conclusions Taking fresh frozen sections during MT using a flex-rigid bronchoscope is a useful diagnostic modality with reliable sensitivity for malignancy. However, if the pre-procedural diagnosis is likely to be a malignancy other than lung cancer, and if severe adhesions are present in the pleural cavity, the final pathological confirmation should be determined based on permanent paraffin sections, not only on fresh frozen sections.

Background Screening for early detection of lung cancer has been performed in high-risk individuals with smoking history. However, researches on the distribution, clinical characteristics, and prognosis of these high-risk individuals in an actual cohort are lacking. Thus, the objective of this study was to retrospectively review characteristics and prognosis of patients with smoking history in an actual lung cancer cohort. Methods The present study used the lung cancer cohort of the Catholic Medical Centers at the Catholic University of Korea from 2014 to 2017. Patients with non-small cell lung cancer were enrolled. They were categorized into high and low-risk groups based on their smoking history using the national lung screening trial guideline. Distribution, clinical characteristics, and survival data of each group were estimated. Results Of 439 patients, 223 (50.8%) patients were in the high-risk group. Patients in the high-risk group had unfavorable clinical characteristics and tumor biologic features. Overall survival of the high-risk group was significantly shorter than that of the low-risk group with both early (I, II) and advanced stages (III, IV). In multivariate analysis, heavy smoking remained one of the most important poor clinical prognostic factors in patients with lung cancer. It showed a dose-dependent relationship with patients’ survival. Conclusions High-risk individuals had poor clinical outcomes. Patients’ prognosis seemed to be deteriorated as smoking amount increased. Therefore, active screening and clinical attention are needed for high-risk individuals.

Obstructive sleep apnea (OSA) is a common disease associated with significant morbidity and mortality. Sleep quality is an important issue; some patients with acute lung injury (ALI) have underlying OSA. However, the potential influences of OSA on ALI have not been reported until now. In this study, we evaluated the impact of preceding intermittent hypoxia (IH), a typical characteristic of OSA, on lipopolysaccharide (LPS)-induced ALI in a mouse model.C57BL/6J mice were randomly divided into four groups: room air-control (RA-CTL), intermittent hypoxia-control (IH-CTL), room air-lipopolysaccharide (RA-LPS), and intermittent hypoxia-lipopolysaccharide (IH-LPS) groups. The mice were exposed to RA or IH (20 cycles/h, FiOThe IH-LPS group tended to exhibit more severe inflammation, fibrosis, and oxidative stress compared to the other groups, including the RA-LPS group. Total cell, neutrophil, and eosinophil counts in bronchoalveolar lavage fluid increased significantly in the IH-LPS group compared to the RA-LPS group. Compared to the RA-LPS group, the hydroxyproline level increased significantly in the IH-LPS group. In addition, the IH-LPS group exhibited significantly more terminal deoxynucleotidyl transferase dUTP nick end labeled-positive cells compared to the RA-LPS group.We found that prior IH may negatively impact LPS-induced ALI in a mouse model. This result suggests that ALI in patients with OSA may be more of a concern. Further research into the mechanisms underlying the effects of IH on ALI is needed.

STUDY OBJECTIVES: To evaluate the readability, content, and quality of internet information about obstructive sleep apnea (OSA). METHODS: Three major search engines (Google, Yahoo, and Bing) were used to retrieve the first 200 hits for the term “sleep apnea.” The website contents were assessed using established guidelines, while the website quality was evaluated using the validated DISCERN instrument and Journal of the American Medical Association benchmarks. RESULTS: In total, 243 websites met the inclusion criteria for this study. The websites were divided into five categories: scientific resource, foundation, news/ media report, commercial website, and personal commentary. The mean Flesch-Kincaid grade level, which indicated the readability of the websites, was 7.5. The quality of most websites was poor, with news/media reports and commercial websites exhibiting poorer quality than the others. The Health On the Net (HON) code, which certifies the reliability and credibility of online content regarding human health, was applied only to 14.3% websites; the reliability of all these websites was poor. The content score for the diagnosis and management of OSA was lower for news/media reports and commercial websites than for scientific resources. News/media reports exhibited the worst content scores. CONCLUSIONS: Our findings suggest that most online health resources regarding OSA are not reliable and are inaccurate. Health care providers should be aware of the high variability in online information concerning OSA. COMMENTARY: A commentary on this article appears in this issue on page 1643. CITATION: Lee J, Ban WH, Park HK, Na E, Kim SK, Kang HH, Lee SH. Accuracy and reliability of internet resources providing information on obstructive sleep apnea. J Clin Sleep Med. 2018;14(10):1717–1723.

Background Smoking histories are independently associated with poor response to epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) in non-small cell lung cancer (NSCLC) patients with activating EGFR mutations. The aim of the present study was to determine the effect of nicotine exposure on programmed death-ligand 1 (PD-L1) expression in EGFR mutant lung cancer cells. Methods Human lung adenocarcinoma PC9 cells were exposed to 1 µM nicotine for 3 months designated as PC9/N, and cells were stimulated with gefitinib (0, 0.1, or 1 µM) for 48 hrs. Cell viability by the MTT assay and morphological changes by immunofluorescence staining were assessed. The protein expression of EGFR, mTOR, AKT, α1-nicotine acetylcholine receptor (nAchR) and PD-L1 were measured by Western blot. Gene expression of α1-nAchR and PD-L1 were examined by RT-PCR. Intratumoral levels of PD-L1 expression were compared according to the burden of smoking dosage in 54 EGFR mutant lung cancer patients. Results Cellular growth was inhibited by treatment with gefitinib, and PC9 cells were significantly more sensitive to gefitinib than PC9/N cells. Pleomorphic appearance with atypical nuclei and to be detached and shrunken with condensed nuclei in PC9 than PC9/N cells. The gene expression level of α1-nAchR and PD-L1 gene were higher in PC9/N cells compared to those in PC9 cells after treatment with gefitinib. Phosphorylation levels of EGFR, mTOR, AKT and PD-L1 level were decreased by gefitinib in PC9/N cells, which was to a lesser extent than that in PC9 cells. In tumors, heavy smokers (≥30 PY) showed 28.5% of ≥50% PD-L1 tumor proportion score (TPS) while light smoker and never smokers had 12.5% and 9.7% of ≥50% PD-L1 TPS, respectively. However, there was no statistical significance (P value =0.628). Conclusions Chronic nicotine exposure could increase PD-L1 expression related to intrinsic resistance to EGFR-TKI in NSCLC patients harboring activating EGFR mutation. Considering the clinical importance of inevitable EGFR resistance, further studies regarding the role of anti-PD-1/PD-L1 treatment are needed, especially in EGFR mutant smokers.

Woo Ho Ban,1 Hyonsoo Joo,1 Jeong Uk Lim,1 Hyeon Hui Kang,2 Hwa Sik Moon,2 Sang Haak Lee2 1Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea; 2Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, St Paul’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Introduction: The detection of insomnia in patients with COPD is assumed to be significantly lower than the actual prevalence. In this study, we investigated the prevalence of insomnia and the relationship between insomnia and health status in patients with COPD using two fairly simple and straightforward questionnaires: COPD assessment test (CAT) and insomnia severity index (ISI). Patients and methods: A cross-sectional study was conducted using data from patients undergoing treatment for COPD at St Paul’s Hospital, The Catholic University of Korea, between December 2015 and August 2016. Patients were classified into three groups according to the ISI score: a “clinical insomnia” group (ISI≥15), a “subthreshold insomnia” group (ISI 8–15), and a “non-insomnia” group (ISI14, giving a sensitivity and specificity of 66.7% and 71.5%, respectively. Conclusion: CAT score was closely related to insomnia severity in patients with COPD. The use of CAT scores to assess for the presence and severity of insomnia in these patients may allow for better detection and management and improve clinical practice. Keywords: chronic obstructive, maintenance disorders, pulmonary disease, sleep initiation

Background Previous studies have reported that microalbuminuria is an independent risk factor for the prevalence of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (DM). For this reason, the clinical significance of DR in normoalbuminuric type 2 DM patients may be overlooked. The aim of this study was to investigate the prevalence of DR and predictors for DR in normoalbuminuric patients with type 2 DM. Methods A total 310 patients with type 2 DM and normoalbuminuria, who were referred to the Department of Ophthalmology for screening of DR were included in this study. DR was clinically graded according to the International Clinical Diabetic Retinopathy guidelines. The urinary albumin excretion rate (UAER) was assessed via 24-hour urine collection and measured by immunoturbidimetric assay. Normoalbuminuria was defined as a UAER Results DR of any grade was present in 64/310 (20.7 %) patients. Mild non-proliferative diabetic retinopathy (NPDR) was most prevalent in patients with DR of any grade (36/64, 56 %). The duration of diabetes (OR 1.01, 95 % CI, 1.01 – 1.02, p Conclusions Our findings suggest that patients with normoalbuminuric type 2 DM also require close monitoring for the early detection of DR, especially if they have a higher UAER, longer duration of diabetes, or lower hemoglobin levels.

Purpose To investigate associations between dyspnea and clinical outcomes in patients with non-small cell lung cancer (NSCLC). Materials and Methods From 2001 to 2014, we retrospectively reviewed the prospective lung cancer database of St. Paul's Hospital at the Catholic University of Korea. We enrolled patients with NSCLC and evaluated symptoms of dyspnea using modified Medical Research Council (mMRC) scores. Also, we estimated pulmonary functions and analyzed survival data. Results In total, 457 NSCLC patients were enrolled, and 259 (56.7%) had dyspnea. Among those with dyspnea and whose mMRC scores were available (109 patients had no mMRC score), 85 (56.6%) patients had an mMRC score

Background/Aims: Anxiety and depression are associated with reflux symptoms in patients with gastroesophageal reflux disease (GERD). The purpose of this study is to investigate whether the anxiety and depression in patients with GERD will improve with anti-secretory treatment. Materials and Methods: Participants who had taken upper endoscopic evaluation and who had symptoms of heartburn or acid regurgitation more than once a week were included through questionnaires. The hospital anxiety and depression scale was used to compare the scores before and after anti-secretory drug (proton pump inhibitor [PPI] or histamine-2 receptor blocker [H2 blocker]) treatment for four weeks. Results: Eighty-four out of a total 94 patients were randomly assigned to a four week treatment, in which, 46 and 38 patients were each assigned to PPI and H2 blocker, respectively. Regardless of the type of treatment, anxiety scores decreased significantly from 5.8±3.8 to 5.2±3.9 after treatment (P=0.033). Depression scores of 6.3±3.4 before treatment reduced to 5.5±3.4 after treatment (P=0.011). Anxiety scores and depression scores decreased significantly after treatment in the H2 blocker group. In the response group, anxiety and depression showed significant improvement (P=0.008, P=0.011). Conclusions: Regardless of the type of drugs, anti-secretory therapy is helpful in treating symptomatic GERD patients, not only in relieving symptoms, but also in relieving anxiety and depression accompanied with GERD. (Korean J Helicobacter Up Gastrointest Res 2013;13:30-35)

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disease. Polycystic liver disease is commonly observed in ADPKD but rarely has it been associated with a choledochal cyst. We report a case of a choledochal cyst with ADPKD in a 60-year-old female patient with ADPKD and concomitant chronic renal failure who was admitted because of acute deterioration of kidney function due to poor oral intake. There was no history of a biliary disorder and her kidney function recovered promptly after fluid replacement. Non-enhanced computed tomography was performed to evaluate ADPKD and revealed numerous cysts in both kidneys and liver. It also showed fusiform dilatation of the extrahepatic bile ducts, a finding indicative of a choledochal cyst. Liver function was within the normal range and there was no evidence of extrahepatic biliary obstruction. Magnetic resonance cholangiopancreatography confirmed the diagnosis of a type I choledochal cyst combined with ADPKD. (Korean J Med 2013;85:205-209)

Herein we report the case of a 71-year-old woman who complained of fatigue and enlarged right axillary lymph nodes for 18 months. At her first visit, her chest X-ray showed diffuse nodular opacities in both lung fields. Initial excisional biopsy of the axillary lymph nodes showed granulomatous lesions and acid fast bacilli were seen on Ziehl-Neelsen staining. However, even after 15 months of anti-tuberculosis (TB) medication, her right axillary lymph nodes were enlarged. We re-performed an excisional biopsy of the nodes, which showed Hodgkin`s lymphoma (HL). A retrograde review of the biopsy before anti-tuberculous medication, revealed HL coexisting with TB. HL and TB cause difficulties in differential diagnosis due to similarities in clinical course, imaging procedures and histopathological analysis of the involved tissue. Therefore, it is important to consider the possibility of concurrent HL and TB when patients who undergo treatment for TB or chemotherapy for lymphoma complain of persistent systemic symptoms or enlarged lymph nodes.