Research status of east Asian traditional medicine treatment for chronic cough: A scoping review

BACKGROUND

When patients continue to experience cough despite conventional treatment, East Asian traditional medicine (EATM) including herbal medicine and/or acupuncture has been frequently used. Previous systematic reviews of EATM treatment for chronic cough have been conducted mainly on herbal medicine, targeting patients with conditions that cause cough. In clinical practice, EATM interventions are not limited to herbal medicine, and considering that chronic cough is often caused by two or more conditions or unspecific causes, a comprehensive investigation is clinically relevant. We examined the current research status of EATM for chronic cough.

METHODS

Based on Arksey and O'Malley's scoping review methodological framework, a total of six English, Chinese, Korean, and Japanese electronic databases were searched on August 2022. Any clinical studies on EATM targeting chronic cough patients (regardless of their cause) were included.

RESULTS

Among 474 included studies, the study designs were mainly randomized controlled trials (72.4%), and the population was evenly distributed between children and adults. The cause of cough was not reported in most studies (56.1%). The common cause of cough was upper airway cough syndrome and post-respiratory infection (9.5%, each), followed by mixed cause (7.6%), nonspecific cause (5.9%), and gastroesophageal reflux disease (4.0%). EATM was conducted for a mean of 19.1 days, and herbal medicine was the most common (80.6%). Conventional medication was frequently used as a control (81.2%). For outcomes, the total effective rate was the most frequently utilized (94.3%), followed by cough severity (53.8%). EATM treatment showed positive outcomes in most studies.

CONCLUSIONS

In future EATM studies, it is necessary to either specify the cause of chronic cough or to report that the study was targeting nonspecific chronic cough. In addition, high-quality studies assessing the efficacy of EATM with placebo control treatment should be conducted, using validated evaluation tools.

The Effectiveness and Safety of Chuna Manual Therapy Adjuvant to Western Medicine in Patients with Chronic Obstructive Pulmonary Disease: A Randomized, Single-Blind, Investigator-Initiated, Pilot Trial

Recently, non-pharmacological treatments are gaining increasing importance for improving the quality of life in patients with chronic obstructive pulmonary disease (COPD). This pilot study aimed to evaluate the feasibility of conducting extensive research on Chuna manual therapy (CMT). This study investigated the effectiveness and safety of CMT adjuvant to Western medicine (WM) in patients with COPD. Forty patients with COPD were randomized into two groups in a 1:1 ratio: experimental (CMT plus WM) and control (WM only) groups. The CMT intervention was administered once a week for eight weeks. The primary outcome measured was the 6-min walk distance (6MWD). Secondary outcomes measured were: forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), assessments using the modified Medical Research Council (mMRC) scale and Visual Analog Scale (VAS) for dyspnea, the COPD Assessment Test (CAT), St. George's Respiratory Questionnaire (SGRQ), and the EuroQoL five-dimensional questionnaire (EQ-5D). The mean differences in FEV1 (L) between Weeks 1 and 8 were statistically significant between the groups (p = 0.039). Additionally, the experimental group showed improved 6MWD, mMRC, VAS for dyspnea, CAT, SGRQ (total), and EQ-VAS scores than the control group. However, the differences between the two groups were not statistically significant. No adverse events were observed during this trial. CMT has the potential to alleviate symptoms, improve quality of life, and delay the decline in lung function in patients with COPD. The results of this pilot study could lead to large-scale clinical trials in the future.

Acetylcorynoline Induces Apoptosis and G2/M Phase Arrest through the c-Myc Signaling Pathway in Colon Cancer Cells

Colorectal cancer (CRC) is the third most commonly diagnosed cancer worldwide, and despite advances in treatment, survival rates are still low; therefore, the development of novel drugs is imperative. Acetylcorynoline (ACN) is derived from Corydalis ambigua Cham. et Schltdl tubers. The effect of ACN on colon cancer is still unknown. Therefore, we investigated its potential effects. Our data showed that ACN inhibited cell viability and proliferation. Moreover, ACN induced apoptosis and cell cycle arrest by inhibiting cell growth. In the present study, we hypothesized that ACN regulates c-Myc through CNOT2 or MID1IP1. ACN reduced the protein expression of oncogenic genes, decreased c-Myc half-life, and rapidly inhibited the serum stimulation response. Moreover, knockdown of CNOT2 and MID1IP1 with ACN increased apoptosis and further reduced the expression of oncogenes. In addition, ACN exhibited a synergistic effect with low-dose 5-fluorouracil (5-FU) and doxorubicin (Dox). Collectively, our data demonstrate that ACN inhibited c-Myc expression through CNOT2 and MID1IP1, and induced apoptosis. These findings indicate the potential of ACN as a therapeutic agent against colon cancer.

Effects of herbal medicines (Eunkyosan/Yin qiao san and Samsoeum/Shen su yin) for treating the common cold: A randomized, placebo-controlled, multicenter clinical trial

Background

Eunkyosan (EKS) and Samsoeum (SSE), which are called Yin qiao san and Shen su yin in Chinese, are commonly used herbal medicines for the common cold in East Asian countries. This study aimed to evaluate the effectiveness and safety of EKS and SSE for treating the common cold.

Methods

A randomized, patient-assessor-blind, placebo-controlled, parallel, and multicenter clinical trial was conducted. Adult participants who had one or more cold within 48 h before screening, were randomly allocated to EKS, SSE, or placebo groups. The recruitment goal was planned to be 375 participants. They took an EKS, SSE, or placebo, thrice daily for up to 8 days. The primary outcome was the change in the total score of the Wisconsin Upper Respiratory Symptom Scale-21-Korean version (WURSS-21-K) on day 6 compared to the baseline. The secondary outcomes included visual analog scale (VAS) scores and the duration of symptoms was assessed throughout the trial.

Results

A total of 128 participants were enrolled and 44, 42, and 42 were allocated to the EKS, SSE, and placebo groups, respectively. This study was prematurely terminated due to the COVID-19 pandemic, and we were unable to recruit all the planned participants (n = 375). EKS showed significant clinical effectiveness over the placebo group in the treatment of the common cold, as assessed by the total, symptom, and quality of life scores of WURSS-21-K and VAS, whereas SSE showed significant improvement over the placebo group in terms of WURSS-21-K symptom score. No severe adverse events were reported.

Conclusions

Although EKS and SSE demonstrated statistically significant clinical effectiveness and safety in patients with the common cold, we failed to recruit our pre-planned number of participants. Future definitive full-scale studies are needed to confirm these results.

Trial registration

ClinicalTrials. gov, registration number: NCT04073511. Registered on 29 August 2019.

Herbal medicine for the treatment of chronic cough: a systematic review and meta-analysis

Objectives: Chronic cough is a frequent condition worldwide that significantly impairs quality of life. Herbal medicine (HM) has been used to treat chronic cough due to the limited effectiveness of conventional medications. This study aimed to summarize and determine the effects of HM on patients with chronic cough. Methods: A comprehensive search of 11 databases was conducted to find randomized controlled clinical trials (RCTs) that reported the effects of HM for patients with chronic cough on 16 March 2023. The primary outcome was cough severity, and the secondary outcomes included cough-related quality of life, cough frequency, total effective rate (TER), and cough recurrence rate. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool, and the certainty of the evidence for effect estimates was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations tool. Results: A total of 80 RCTs comprising 7,573 patients were included. When HM was used as an alternative therapy to conventional medication, there were inconsistent results in improving cough severity. However, HM significantly improved cough-related quality of life and TER and significantly lowered the cough recurrence rate compared with conventional medication. When used as an add-on therapy to conventional medication, HM significantly improved cough severity, cough-related quality of life, and TER and significantly lowered the recurrence rate. In addition, HM had a significantly lower incidence of adverse events when used as an add-on or alternative therapy to conventional medication. The subgroup analysis according to age and cause of cough also showed a statistically consistent correlation with the overall results. The certainty of the evidence for the effect of HM was generally moderate to low due to the risk of bias in the included studies. Conclusion: HM may improve cough severity and cough-related quality of life, and lower the cough recurrence rate and incidence of adverse events in patients with chronic cough. However, due to the high risk of bias and clinical heterogeneity of the included studies, further high-quality placebo-controlled clinical trials should be conducted using a validated and objective assessment tool. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023418736, CRD42023418736.

The Antitumor Effect of Timosaponin A3 through c-Myc Inhibition in Colorectal Cancer Cells and Combined Treatment Effect with 5-FU or Doxorubicin

Timosaponin A3 (TA3), extracted from the rhizome of Anemarrhenaasphodeloides Bunge, has been reported to affect various diseases, such as cancer, Alzheimer’s disease, and allergies. However, the underlying molecular mechanisms and impacts are largely unknown. In the present study, we hypothesized that TA3 induces apoptosis through the inhibition of c-Myc expression via CNOT2 or MID1IP1 in HCT116. An MTT assay and colony formation assay were used to measure cell viability and proliferation. The protein expression of apoptotic markers and oncogenes was measured using immunoblotting and immunofluorescence assays. The interaction between MID1IP1 and c-Myc was confirmed by performing an immunoprecipitation assay. TA3 markedly inhibited colon cancer cell proliferation. Consistently, TA3 regulated the apoptotic proteins pro-PARP and caspase 3. TA3 inhibited the half-life of c-Myc and suppressed its expression in response to serum stimulation. In addition, TA3 enhanced the apoptotic effects of doxorubicin and 5-FU in colon cancer cells. Altogether, our results reveal a mechanism by which TA3 induces apoptosis through inhibiting c-Myc expression via CNOT2 or MID1IP1 in HCT116, which may help in the development of new therapies for colon cancer based on TA3 in the future.

Therapeutic Potential of Chungsangboha-tang for the Treatment of Asthma: A Review of Preclinical and Clinical Studies

In traditional Korean medicine, Chungsangboha-tang (CSBHT) and its modified forms are used to treat various respiratory disorders, including asthma. This study aimed to identify research trends, clarify the effectiveness of CSBHT and related prescriptions, and lay a foundation for future research. We conducted a literature review using PubMed, Embase, Google Scholar, Oriental Medicine Advanced Searching Integrated System, National Digital Science Links, Korean Medical Database, Wanfang Data, and Chinese National Knowledge Infrastructure databases. We analyzed 25 studies, including 5 in vitro studies, 6 animal studies, and 14 human studies. Many studies evaluated the efficacy of CSBHT and its related prescriptions, including experimental studies on its effectiveness in asthma. The main mechanism of action involves the anti-inflammatory effect caused by the regulation of various immune cells, cytokines, and chemokines. In addition, clinical trials on asthma reported the benefits of CSBHT and its related prescriptions. However, there has been no randomized controlled study of clinical trials on the clinical effectiveness of CSBHT in asthma. Therefore, large-scale randomized controlled studies should be conducted in the future.

Rosa laevigata Attenuates Allergic Asthma Exacerbated by Water-Soluble PM by Downregulating the MAPK Pathway

Exposure to water-soluble particulate matter (WPM) containing heavy metals can cause severe inflammatory responses and trigger and exacerbate the onset of asthma. As a follow-up study of Rosa laevigata (RL), this study analyzed the therapeutic effects and mechanisms of oral and intratracheal administration of RL and demonstrated anti-inflammatory effects in asthma models. Worse T-helper cell type 2 (Th2)-related inflammatory and pro-inflammatory responses were observed after simultaneous challenge with ovalbumin (OVA) and WPM. To establish a model of asthma exacerbated by WPM, BALB/c mice were sensitized with OVA + aluminum hydroxide and challenged with OVA + WPM. To confirm the therapeutic efficacy of RL, it was administered both orally and intratracheally. Histopathological analysis of H&E staining confirmed that oral and intratracheal administration of RL alleviated inflammatory cell infiltration in the airways aggravated by OVA + WPM. RL effectively reduced the number of inflammatory cells obtained from the bronchoalveolar lavage fluid. In addition, enzyme-linked immunosorbent assay (ELISA) and multiplex analysis of serum samples confirmed that the administration of RL reduced the levels of immuno-globulin E (IgE), Th2-related cytokines, and pro-inflammatory cytokines. Furthermore, real-time PCR analysis of lung tissue samples confirmed that the release of MUC5AC (Mucin 5AC, Oligomeric Mucus/Gel-Forming) and pro-inflammatory cytokines was reduced by RL, and western blotting confirmed that the administration of RL reduced the phosphorylation of ERK and p38 in the MAPK pathway. In conclusion, oral and intratracheal administration of RL appears to have an anti-asthmatic effect by reducing the secretion of Th2-related cytokines, pro-inflammatory cytokines, and IgE by downregulating the MAPK pathway. Thus, RL has further demonstrated potential for development as an oral and inhaled therapeutic for asthma symptoms exacerbated by WPM exposure.

Leonurus japonicus Houttuyn induces reactive oxygen species-mediated apoptosis via regulation of miR-19a-3p/PTEN/PI3K/AKT in U937 and THP-1 cells

ETHNOPHARMACOLOGICAL RELEVANCE

Leonurus japonicus Houttuyn is a medicinal ingredient in more than 300 prescriptions in traditional Korean medicine. It is especially important for women's health and blood-related diseases. Recent research revealed that Leonurus japonicus Houttuyn extracts have antioxidative, anticancer, analgesic, anti-inflammatory, and neuroprotective properties.

AIM OF THE STUDY

However, its underlying anti-cancerous mechanisms remain unclear. This study elucidated the anticancer mechanism of Leonurus japonicus Houttuyn in U937 and THP-1 cancer cells.

MATERIALS AND METHODS

High-performance liquid chromatography (HPLC) was used for detecting main compound of Leonurus japonicus Houttuyn, rutin. EZ-Cytox cell viability assay, Western blot analysis, live and dead cell assay, 2', 7' dichlorofluorescin diacetate (DCFDA) assay, quantitative real-time PCR (qRT-PCR) analysis, and microRNA (miR) mimic transfection assay were applied to further investigate anti-cancer efficacies and underlying mechanism in U937 and THP-1 cells.

RESULTS

The main compound of Leonurus japonicus Houttuyn, rutin was detected using HPLC. The cytotoxic effect of Leonurus japonicus Houttuyn was exerted in U937 and THP-1 cancer cells but not in MDBK and IEC-6 normal cells. Leonurus japonicus Houttuyn decreased mitochondria membrane potential (ΔΨm). Consistently, Leonurus japonicus Houttuyn reduced the expression of survivin and cleaved caspase-9, caspase-3, and poly (ADP-ribose) polymerase (PARP). Cell death was increased in Leonurus japonicus Houttuyn treated groups. Phosphatase and tensin homolog deleted on chromosome 10 (PTEN) and CCAAT-enhancer-binding protein homologous protein (CHOP) was increased and phosphatidylinositol-3-kinase (PI3K) and Protein kinase B (AKT) were decreased by Leonurus japonicus Houttuyn. Reactive oxygen speices generation was elevated by Leonurus japonicus Houttuyn and its cytotoxicity was reversed by N-acetyl-l-cysteine (NAC) pretreatment. Moreover, onco-microRNA (miR), miR-19a-3p was suppressed by Leonurus japonicus Houttuyn and transfection of miR-19a-3p mimic reversed the regulated PTEN, p-AKT, CHOP expression, attenuating Leonurus japonicus Houttuyn induced apoptosis.

CONCLUSIONS

These findings indicated that Leonurus japonicus Houttuyn has anti-cancer effects by regulation of PTEN/PI3K/AKT signal pathway and ROS-related ER stress-induced apoptosis via regulation of miR-19a-3p. Leonurus japonicus Houttuyn may be an effective candidate for triggering PTEN-dependent apoptosis of cancer cells related to acute myeloid leukemia.

Efficacy and Safety of Ojeok-San Plus Saengmaek-San for Gastroesophageal Reflux-Induced Chronic Cough: A Pilot, Randomized, Double-Blind, Placebo-Controlled Trial

Introduction: Gastroesophageal reflux-induced chronic cough (GERC) is one of the most common etiologies of chronic cough. Despite the growing prevalence and interest in GERC, no effective treatment is currently available. In our study, we used a combination of herbal medicines, Ojeok-san (OJS) plus Saengmaek-san (SMS), for the treatment of GERC. Methods: We conducted a pilot, randomized, placebo-controlled, parallel-arm, single-center clinical trial to assess the feasibility of our study protocol, as our study is the first herbal medicine trial for GERC. All enrolled participants were randomly assigned to either the intervention or placebo group in a 1:1 ratio and were administered trial drugs three times a day for 6 weeks, with an evaluation visit performed every 2 weeks for their efficacy and safety assessment until the follow-up visit (week 8). We evaluated the severity and frequency of cough, cough-specific quality of life, airway hypersensitivity, and reflux-related gastrointestinal symptoms, as well as pattern identification, to investigate the complex mechanisms of reflux cough syndrome. Results: A total of 30 participants were enrolled, and 25 completed the study at Kyung Hee University Korean Medicine Hospital from 26 December 2018 to 31 May 2021. OJS plus SMS significantly improved the cough diary score (CDS), cough visual analog scale, Korean version of the Leicester Cough Questionnaire, Hull Airway Reflux Questionnaire, and Gastrointestinal Symptom Rating Scale after the treatment compared to the baseline. Notably, OJS plus SMS showed significant efficacy in the daytime and total CDS compared with the placebo. Only one adverse event was observed during the trial, and no serious adverse events occurred. Additionally, we achieved successful results in feasibility outcomes by exceeding the ratio of 80%. Conclusion: We confirmed the feasibility of our trial design and demonstrated the potential of OJS plus SMS in relieving the severity of cough and GI symptoms in GERC patients with safe and successful feasibility results. We anticipate that our study results will be used as the basis for further large-scale, well-designed, confirmatory trials to evaluate the safety and efficacy of OJS plus SMS in GERC. Clinical Trial Registration: [https://cris.nih.go.kr], identifier WHO International Clinical Trials Registry Platform, Clinical Research Information Service [KCT0003115].

Current status of herbal medicine research for respiratory diseases induced by particulate matter: a protocol for a scoping review

BACKGROUND

Particulate matter (PM) is an important environmental risk factor for the initiation and exacerbation of respiratory disease. Various herbal medicines have exhibited a reduction in symptoms of respiratory diseases induced by PM in animal models. However, the types and characteristics of studies on herbal medicine for respiratory diseases by PM have not been reviewed. This scoping review will focus on the currents status and research gap of herbal medicines for respiratory diseases caused by PM.

METHODS

We will follow the scoping review framework developed by Arksey and O'Malley. MEDLINE (via PubMed), EMBASE, and the Cochrane Central Register of Controlled Trials will be searched for relevant English-language publications, and only peer-reviewed, controlled comparative in vivo/in-vitro/human studies examining the effects of herbs on respiratory disease induced by PM will be included. The basic characteristics, research methods, detailed regimens, possible mechanisms, outcomes, and results will be extracted using a predefined standardized data extraction form. Outcomes will be presented in the following categories: pulmonary function, inflammatory markers, reactive oxygen species, histology and mechanisms, and adverse events. Two researchers will independently perform the study selection, data extraction, and quality assessment. We will also present the research map and implications for further study.

ETHICS AND DISSEMINATION

Ethical approval is not required because individual patient data will not be included. The findings will be disseminated through peer-reviewed publications or conference presentations.

SYSTEMATIC REVIEW REGISTRATION

This review protocol has been registered with the Open Science Framework on February 12, 2021 ( https://osf.io/s7uvk/ ).

Herbal Medicine Compared to Placebo for Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Chronic obstructive pulmonary disease (COPD) is a respiratory disease characterized by irreversible airflow limitation. Many COPD patients use complementary and alternative modalities, including herbal medicines (HMs). This systematic review investigated the effectiveness and safety of HM in managing COPD symptoms compared to placebo. Nine electronic databases were searched to identify relevant randomized controlled trials (RCTs) up to February 12, 2021. The Cochrane risk of bias tool was used to assess the methodological qualities of the included studies. Primary outcomes were lung function parameters and exercise capacity. A meta-analysis was conducted to determine the effect size for homogeneous outcomes. Fourteen studies were included. There was low to very low quality evidence that HM significantly improved forced expiratory volume in 1  s (FEV1) (L), FEV1 (%) and 6-minute walk distance, as well as moderate quality evidence that HM significantly improved forced vital capacity (FVC) (L) compared to placebo. However, according to low quality evidence, there was no significant difference in FEV1/FVC (%) or vital capacity (L) between the groups. Low to moderate evidence suggests that HM has the potential to help improve some respiratory functions, COPD symptoms, and some aspects of quality of life in COPD patients compared to placebo. However, these findings are challenged by the poor methodological quality of the included studies, the heterogeneity of HMs used, and potential publication bias. Therefore, the findings could be significantly influenced by further larger, more rigorous RCTs on this topic. Moreover, it may also be recommended to develop standardized HMs focused on some individual herbs that are frequently used or expected to play an important role in patients with COPD, and to elucidate the underlying mechanisms.

The Natural Products Targeting on Allergic Rhinitis: From Traditional Medicine to Modern Drug Discovery

More than 500 million people suffer from allergic rhinitis (AR) in the world. Current treatments include oral antihistamines and intranasal corticosteroids; however, they often cause side effects and are unsuitable for long-term exposure. Natural products could work as a feasible alternative, and this study aimed to review the efficacies and mechanisms of natural substances in AR therapies by examining previous literature. Fifty-seven studies were collected and classified into plants, fungi, and minerals decoction; clinical trials were organized separately. The majority of the natural products showed their efficacies by two mechanisms: anti-inflammation regulating diverse mediators and anti-oxidation controlling the activity of nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) pathway stimulated by reactive oxygen species (ROS). The main AR factors modified by natural products included interleukin (IL)-4, IL-5, IL-13, interferon-gamma (IFN-γ), tumor necrosis factor-α (TNF-α), cyclooxygenase 2 (COX-2), and phospho-ERK1/2 (p-ERK1/2). Although further studies are required to verify their efficacies and safeties, natural products can significantly contribute to the treatment of AR.

The effectiveness and safety of Chuna manual therapy adjuvant to Western medicine in patients with chronic obstructive pulmonary disease: Study protocol for a randomized, single-blind, investigator-initiated, pilot trial

BACKGROUND

In chronic obstructive pulmonary disease (COPD) management, greater emphasis has been placed on symptomatic improvement and enhanced quality of life in patients. Manual therapy among respiratory rehabilitation programs has received much attention recently, with the publication of numerous studies. In South Korea, a method known as Chuna Manual Therapy (CMT) has been applied in the management of COPD patients and in clinical practice, but the clinical basis for safety and effectiveness is yet to be established. Therefore, rigorously designed randomized controlled trials are required. We aimed to evaluate the feasibility of assessing the add-on effect and safety of CMT administered with standard Western medicine therapy for the treatment of COPD.

METHODS

This is a randomized, single-blind, single-center clinical pilot trial. Patients with COPD receiving standard drug therapy are randomly divided into an experimental group (n = 20) and a control group (n = 20) at a 1:1 ratio. The experimental group receives CMT adding to the standard medical therapy once a week for 8 weeks. The control group receives only the standard drug treatment. The trial is conducted with an outcome assessor and statistician blinding. The primary outcome is the 6-minute walk test. The secondary outcomes include the pulmonary function test, the Modified Medical Research Council, visual analog scale for dyspnea, COPD assessment test, quality of life using the St. George's respiratory questionnaire, EuroQOL five dimensions questionnaire, and Korean pattern identification questionnaire. Adverse events are also be evaluated.

CONCLUSIONS

The results of this study will provide the feasibility of a large-scale clinical trial to establish high-quality clinical evidence of CMT for COPD.

TRIAL REGISTRATION

Korean Clinical Trial Registry (http://cris.nih.go.kr; registration number: KCT0006119).

Comparative Effectiveness of Western and Eastern Manual Therapies for Chronic Obstructive Pulmonary Disease: A Systematic Review and Network Meta-Analysis

Background: Manual therapy (MT) is considered a promising adjuvant therapy for chronic obstructive pulmonary disease (COPD). Comparing the effectiveness among different Western and Eastern MTs being used for the management of COPD could potentially facilitate individualized management of COPD. This systematic review attempted to estimate the comparative effectiveness of Western and Eastern MTs for COPD patients using a network meta-analysis (NMA) methodology. Methods: Nine electronic databases were comprehensively searched for relevant randomized controlled trials (RCTs) published up to February 2021. Pair-wise meta-analysis and NMA were conducted on the outcomes of COPD, which included lung function and exercise capacity. Results: The NMA results from 30 included RCTs indicated that the optimal treatment for each outcome according to the surface under the cumulative ranking curve was massage, acupressure, massage, and tuina for forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC, and 6 min walking distance, respectively. Conclusions: MTs such as massage, acupressure, and tuina have shown comparative benefits for lung function and exercise capacity in COPD. However, the methodological quality of the included studies was poor, and the head-to-head trial comparing the effects of different types of MTs for COPD patients was insufficient. Therefore, further high-quality RCTs are essential.

Gancaonin N from Glycyrrhiza uralensis Attenuates the Inflammatory Response by Downregulating the NF-κB/MAPK Pathway on an Acute Pneumonia In Vitro Model

Acute pneumonia is an inflammatory disease caused by several pathogens, with symptoms such as fever and chest pain, to which children are particularly vulnerable. Gancaonin N is a prenylated isoflavone of Glycyrrhiza uralensis that has been used in the treatment of various diseases in oriental medicine. There are little data on the anti-inflammatory efficacy of Gancaonin N, and its effects and mechanisms on acute pneumonia are unknown. Therefore, this study was conducted as a preliminary analysis of the anti-inflammatory effect of Gancaonin N in lipopolysaccharide (LPS)-induced RAW264.7 cells, and to identify its preventive effect on the lung inflammatory response and the molecular mechanisms underlying it. In this study, Gancaonin N inhibited the production of NO and PGE2 in LPS-induced RAW264.7 cells and significantly reduced the expression of iNOS and COX-2 proteins at non-cytotoxic concentrations. In addition, in LPS-induced A549 cells, Gancaonin N significantly reduced the expression of COX-2 and pro-inflammatory cytokines, such as TNF-α, IL-1β, and IL-6. Moreover, Gancaonin N reduced MAPK signaling pathway phosphorylation and NF-κB nuclear translocation. Therefore, Gancaonin N relieved the inflammatory response by inactivating the MAPK and NF-κB signaling pathways; thus, it is a potential natural anti-inflammatory agent that can be used in the treatment of acute pneumonia.

The efficacy of manual therapy for chronic obstructive pulmonary disease: A systematic review

Background

Manual therapy (MT) can be beneficial in the management of chronic obstructive pulmonary disease (COPD). However, evidence of the efficacy of MT for COPD is not clear. Therefore, we aimed to review the effects of MT, including Chuna, in people diagnosed with COPD.

Methods

MEDLINE via PubMed, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Database (CNKI), KoreaMed, Korean Medical Database (KMbase), and Oriental Medicine Advanced Searching Integrated System (OASIS) were searched. Randomized controlled trials (RCTs) and crossover RCTs were included. The main inclusion criteria were COPD diagnosis (forced expiratory volume in the first second [FEV₁]/forced vital capacity [FVC] < 0.70). The primary outcomes were lung function and exercise capacity. The secondary outcomes were symptoms, quality of life (QoL), and adverse event (AE)s. Studies reporting one or both of the primary outcomes were included. The Cochrane RoB 2.0 tool was used to assess the risk of bias. Data synthesis and analysis were conducted according to the trial design.

Results

Of the 2564 searched articles, 13 studies were included. For the primary outcomes, the effect of MT on pulmonary function and exercise capacity in COPD was partly significant but could not be confirmed due to the limited number of studies included in the subgroups. For the secondary outcomes, no definitive evidence regarding the improvement of symptoms and QoL was found, and some minor adverse effects were reported.

Conclusions

There is insufficient evidence to support the role of MT in the management of COPD. High-quality studies are needed to thoroughly evaluate the effect of MT on COPD.

The Efficacy and Safety of Acupuncture for Preventing Radiation Pneumonitis in Patients With Lung Cancer: A Prospective, Single-Blinded, Randomized Pilot Proof-of-Principle Study

Purpose: We evaluated the efficacy and safety of acupuncture for prevention of radiation pneumonitis in patients with lung cancer. Methods: Twenty-five patients were prospectively enrolled in this study and randomized to either intervention group or control group. The patients assigned to the intervention group received 15 minutes of acupuncture treatment twice a week. The patients assigned to the control group received RT alone without acupuncture treatment. The primary endpoint was incidence of radiation pneumonitis. The secondary endpoints were FEV1 (forced expiratory volume in 1 second), DLCO (diffusing capacity for carbon monoxide), 6-minute walk distance, and modified Borg scale. Results: The intervention group showed lower incidences of grade 3 and grade ≥2 radiation pneumonitis than the control group (10% vs 30% for grade 3 and 50% vs 60% for grade ≥2). In the control group, mean DLCO value was decreased from 62.1% at baseline to 49.1% after RT (P = .004). The DLCO was also decreased after RT in the intervention group, but the decrement was not statistically significant (56.7% at baseline and 50.9% after RT, P = .204). The FEV1 and 6-minute walk distance were decreased after RT in the control group. However, FEV1 and 6-minute walk distance were increased after RT in the intervention group. Conclusions: This study found that patients who received acupuncture treatment showed a lower incidence of radiation pneumonitis and a protective effect against aggravation of pulmonary function after RT in patients with lung cancer. To confirm the results of this study, well-designed randomized studies with large sample sizes will be required.

Long-term progression-free survival in a patient with advanced non-small-cell lung cancer treated with low-dose gefitinib and traditional herbal medicine: A case report

RATIONALE

Gefitinib is a first-line palliative chemotherapy drug used to treat advanced non-small-cell lung cancer (NSCLC) in patients who have an epidermal growth factor receptor (EGFR) mutation. However, approximately two-thirds of NSCLC patients with EGFR-tyrosine kinase inhibitor experience dermatological toxicity. Cutaneous toxicity is usually not life threatening but can necessitate modification or discontinuation of medication in severe cases. In this case, despite a reduction in the dose of gefitinib due to side effects, combined treatment with modified Bojungikki-tang (BJKIT) increased progression-free survival (PFS) in an advanced NSCLC patient.

PATIENT CONCERNS

An 83-year-old Asian woman presented with chief complaints of chronic cough, dyspnea, weight loss, and anorexia.

DIAGNOSES

The patient was diagnosed with stage IV NSCLC (T2aN3M1), adenocarcinoma with metastasis to the lymph node, brain, and bone based on image scan and biopsy. An EGFR deletion was detected in exon 19.

INTERVENTIONS

The patient was treated with gefitinib (250 mg/d) and traditional herbal medicine, modified Bojungikki-tang (BJIKT). However, after 1 year of combination therapy, gefitinib was tapered down to once per week while modified BJIKT was maintained.

OUTCOMES

A partial response was achieved, but after 3 months severe papulopustular skin rashes developed and became aggravated with time. Thus, the gefitinib dose was reduced. However, the PFS has been maintained for approximately 78 months.

LESSONS

Despite the reduction in gefitinib dose due to side effects, the combined treatment of gefitinib and the modified BJIKT has maintained a PFS of over 78 months, indicating that modified BJIKT enhanced the anti-cancer effect of gefitinib in a patient with advanced NSCLC harboring the EFGR mutation, and may have delayed acquired resistance, the main limitation on the efficacy of gefitinib. Further investigations including clinical trials are needed to confirm these effects.

Effectiveness and safety of herbal medicine for cancer-related fatigue in lung cancer survivors: A systematic review and meta-analysis

Approximately half of lung cancer patients (LCP) receiving chemotherapy are experiencing cancer-related fatigue (CRF). In East Asia, herbal medicines (HMs) have been used as tonics due to their anti-fatigue effect. This systematic review evaluated the effectiveness and safety of HMs for CRF in LCP. We comprehensively searched 12 electronic medical databases to search randomized controlled trials (RCTs) and quasi-RCTs investigating HMs for CRF in LCP, published up to September 2019. The primary outcome was the fatigue severity. Secondary outcomes included patients' quality of life (QOL), activities of daily life (ADL), and incidence of adverse events. Cochrane's risk of bias tool assessed the methodological quality of included RCTs. The risk ratio or mean difference was estimated with 95% confidence intervals by performing a meta-analysis. Twelve RCTs with 861 participants were included. Compared to conventional medicine alone, HM combined with conventional medicine significantly improved fatigue level, QOL, and ADL. As monotherapy, HM significantly improved ADL compared with megestrol. No serious HM-related adverse events were reported. Limited evidence suggests that HM could be effective and safe for CRF in LCP. However, further high-quality RCTs are needed to confirm these findings owing to the small number and low methodological quality of the included studies.

A consensus guideline of herbal medicine for coronavirus disease 2019

Background

The Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV-2), which originated in Wuhan, Hubei Province, China in late December 2019, is the cause of ongoing pandemic. We analyzed the symptoms of SARS-CoV-2, a classification of the Chinese medicine dialectic and treatment regimen, and promptly enacted the recommendation of Korean medicine preparations in herbal medicine covered under domestic medical insurance benefits depending on the circumstances in our country.

Method

The clinical practice guideline (CPG) for the treatment of SARS-CoV-2 was developed based on consensus from a group of experts.

Results

Two kinds of herbal medicines (HM) were recommended for the prevention of SARS-CoV-2; Youngyopaedoc-san plus Bojungikgitang, and Youngyopaedoc-san plus Saengmaek-san. Two herbal preparations were recommended for people with a history of exposure to SARS-CoV-2; Youngyopaedoc-san plus Bulhwangeumjeonggi-san, and Youngyopaedoc-san plus Bojungikgi-tang. Three herbal preparations were recommended for mildly symptomatic COVID-19 patients; Youngyopaedoc-san plus Galgunhaegui-tang was recommended for those without pneumonia with wind-warmth disease invading the lungs; Sosiho-tang plus Bulhwangeumjeonggi-san was recommended for those with dampness-heat disease in the lungs. For the recovery stage, Samchulkunbi-tang plus Saengmaek-san, or Samchulkunbi-tang plus Chungseuiki-tang was recommended.

Conclusion

The CPG was developed to guide the use of Korean herbal medicine in the treatment of SARS-CoV-2, and it is expected that this will be the basis for providing proper treatment of similar infectious diseases in the future.

Efficacy and safety of herbal medicine (Dangguijagyag-san) for primary dysmenorrhea: study protocol for a randomized, double-blind, placebo-controlled, parallel-group, multi-center trial

BACKGROUND

Dangguijagyag-san, also known as Dangguishaoyao-san in Chinese and Toki-shakuyakui-san in Japanese, has been frequently used to treat symptoms associated with dysmenorrhea. The purpose of this trial is to evaluate the efficacy and safety of the herbal medicine, Dangguijagyag-san, relative to those of active control, Gamisoyo-san, and a placebo control for primary dysmenorrhea.

METHODS

This protocol details a randomized, double-blind, parallel-group, multi-center, investigator-initiated, controlled trial evaluating treatment of primary dysmenorrhea. Two hundred and forty participants will be randomly divided into one of three groups: 1) the Dangguijagyag-san experimental group (EG) (n = 105), 2) the Gamisoyo-san active control group (ACG) (n = 30), and 3) the placebo control group (PCG) (n = 105). The interventions will be administered for two menstrual cycles, and the follow-up will be carried out for the following six menstrual cycles. The primary outcomes are difference in response rates between the EG and the ACG (non-inferiority comparison) and difference in changes from baseline in average pain intensity measured by the visual analogue scale between the EG and PCG (superiority comparison). The secondary outcomes are pain scores derived from pain assessment tools (verbal multidimensional scoring system, retrospective symptom scale, and short form McGill pain questionnaire), dosage of analgesics, pattern diagnosis questionnaires, and short form 36 health survey. Adverse events and vital signs will be checked at every visit, and laboratory tests will be performed for safety evaluation.

DISCUSSION

The results of this clinical trial will offer evidence for the efficacy and safety of Dangguijagyag-san for primary dysmenorrhea.

TRIAL REGISTRATION

Clinical Research Information Service of Korea: KCT0003005.

Perception, attitude, and demand for Korean medicine and Western medicine collaborative treatment of medical occupational groups in Korea: A scoping review

Background

In Korea, there exists a dual medical license system whereby both traditional Korean medicine and Western medicine doctors practice independently. In 2009, via medical law revision, cross employment was allowed to activate Korean medicine and Western medicine collaborative treatment (KWCT). Despite its several advantages, there are several barriers to a well-organized KWCT. To activate KWCT, we investigated perception, attitude, demand of medical occupational groups and research gap via scoping review.

Methods

Scoping review is an emerging methodology for knowledge synthesis adopting the Arksey and O’Malley framework. The research question was “What is known about perception, attitude, demand, and research gap on KWCT?” We searched articles published from 2009 to 2019 in 7 Korean and 4 English databases. We conducted descriptive and qualitative thematic analysis and presented the research gap.

Results

From 1,305 articles, 6 quantitative and 3 qualitative studies were included. In quantitative studies, perception and attitude of medical occupational groups did not change markedly. For better perception and attitude, experiencing, mutual understanding, and respect should precede. Academic exchange, education, supporting KWCT research and legal/institutional/administrative support is also important. In qualitative studies, education course, guidelines, trust, safety, academic integration, and scientification were also required. We found several research gaps about KWCT especially detailed on-site demand and activation strategy about KWCT.

Conclusion

We investigated perception, attitude, and demand on KWCT. Based on research gap in our scoping review, quantitative studies using validated questionnaire and in-depth interview are needed to identify on-site demand to improve KWCT implementation.

Protocol registration

https://www.researchregistry.com/(reviewregistry830)

Herbal medicines (Eunkyosan and Samsoeum) for treating the common cold: a protocol for a randomized, placebo-controlled, multicenter clinical trial

Background

The common cold is the most frequent acute respiratory illness that places a burden on society, both personally and economically. There is no standard therapy; only symptomatic therapy remains the mainstay of common cold treatment. Thus, interest in herbal medicines is on the rise. Eunkyosan and Samsoeum are used for the common cold in East Asian countries. Although Eunkyosan and Samsoeum are clinically used for the treatment of the common cold, their effectiveness and safety have yet to be studied. Therefore, we aimed to evaluate their effectiveness and safety.

Methods

This study is a randomized, patient-assessor blind, controlled, parallel, and multicenter clinical trial. A total of 375 participants diagnosed with the common cold will be enrolled via four hospitals. The common cold patients will take a daily dose of Eunkyosan or Samsoeum or a placebo, three times a day for eight days. The primary outcome is the change in total Wisconsin Upper Respiratory Symptom Scale-21-Korean version (WURSS-21-K) score between baseline and six days. The secondary outcome includes the visual analogue scale (VAS). Safety is evaluated and adverse events are assessed throughout the trial. Written informed consent will be obtained from all study participants before enrollment.

Discussion

This results will be published in a peer-reviewed journal and disseminated in related conferences.

Trial Registration

ClinicalTrials. gov, registration number: NCT04073511.

The efficacy of manual therapy (Chuna) for chronic obstructive pulmonary disease: Protocol for a systematic review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a challenging disease whose prevalence has increased over the last decades. Non-pharmacological therapies such as pulmonary rehabilitation occupy a core position in patient management. Among these therapies, manual therapy reduces symptoms and increases exercise capacity targeting musculoskeletal problems. Chuna, a traditional Korean manual therapy, has improved pulmonary disorders in clinical practice but unfortunately has not had its effects reported. This systematic review aims to evaluate the effectiveness and safety of manual therapy, focused on the use of Chuna in the management of COPD patients.

METHODS

The following databases will be used in this study: MEDLINE via PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), China National Knowledge Database (CNKI), KoreaMed, Korean Medical Database (KMbase), and Oriental Medicine Advanced Searching Integrated System (OASIS). The primary outcome comprises lung function and exercise capacity. Secondary outcomes included symptoms, quality of life, and adverse events. We will include randomized controlled trials (RCTs) and crossover studies. Two independent reviewers will screen the searched studies, determine if they are suitable for inclusion, and perform data extraction. The risk of bias will be assessed using the Cochrane risk of bias tool. When appropriate, data will be pooled across studies for meta-analysis using a fixed or random effects model. When quantitative synthesis is not appropriate, the evidence will be summarized qualitatively.

RESULTS

This study will provide a comprehensive review of the available evidence to assess the efficacy of Chuna for COPD patients. Results will be published in a peer-reviewed journal and disseminated electronically and in print.

CONCLUSIONS

This study will provide high-quality current evidence for evaluation the efficacy of Chuna for patients with COPD. Clinicians, patients and policy makers may find this review useful in making decisions regarding the use of Chuna for patients with COPD.

PROSPERO REGISTRATION NUMBER

CRD42019141150.

Efficacy and safety of Ojeok-san plus Saengmaek-san for gastroesophageal reflux-induced chronic cough: protocol for a pilot, randomized, double-blind, placebo-controlled trial

BACKGROUND

Gastroesophageal reflux disease (GERD) is a major cause of chronic cough. GERD-induced chronic cough is difficult to diagnose because some patients do not complain of any gastrointestinal (GI) reflux symptoms. Although chronic cough due to GERD is highly prevalent, no effective treatment is currently available, especially for GERD-related cough without GI symptoms. Because the herbal medicines Ojeok-san and Saengmaek-san can effectively treat GERD and cough, we aim to evaluate the efficacy and safety of a combination of these components for relieving chronic cough due to GERD.

METHODS/DESIGN

This is a study protocol of a randomized, double-blind, placebo-controlled, single-center pilot trial. After a 1-week run-in period, a total of 30 patients with GERD-induced chronic cough will be randomly allocated to an intervention group (n = 15) or a placebo group (n = 15). Participants will receive 5.76 g of Ojeok-san plus Saengmaek-san or a placebo three times per day for 6 weeks. The primary outcome measures, which are the frequency and severity of cough, will be recorded using a cough diary. The secondary outcome measures will include a cough visual analogue scale, the Leicester Cough Questionnaire (Korean version), the Gastrointestinal Symptom Rating Scale, the Hull Airway Reflux (hypersensitivity) Questionnaire, the Pattern Identification for Chronic Cough Questionnaire, the Pattern Identification for Gastroesophageal Reflux Disease, and safety testing. Adverse events will also be reported.

DISCUSSION

This will be the first clinical trial to explore the use of herbal medicines for GERD-related chronic cough, including patients without GI reflux symptoms. This study will provide useful evidence regarding the efficacy and safety of Ojeok-san plus Saengmaek-san treatment. In addition, this trial will offer a scientific basis for the combination of herbal medicines. This study will also provide important data for conducting a larger-scale clinical trial on GERD-induced chronic cough.

TRIAL REGISTRATION

This trial has been registered with Clinical Research Information Service (CRIS) of South Korea (http://cris.nih.go.kr; registration number KCT0003115). Registered August 28, 2018.

Herbal medicine on cancer-related fatigue of lung cancer survivors: Protocol for a systematic review

BACKGROUND

Lung cancer is one of the most common cancers worldwide, and approximately half of the patients with lung cancer receiving chemotherapy suffer from cancer-related fatigue (CRF). Herbal medicines (HMs) have been used in Oriental countries for centuries as tonics. Various beneficial effects of HM on fatigue and cancer have been reported. However, the effectiveness and safety of HM for CRF in lung cancer patients have not been synthesized. The purpose of this systematic review is to evaluate the effectiveness and safety of HM for CRF in patients with lung cancer, regardless of their cancer type or stage.

METHODS AND ANALYSIS

A comprehensive search will be conducted in 12 electronic medical databases including 5 English-language databases (Medline via PubMed, EMBASE via Elsevier, the Cochrane Central Register of Controlled Trials [CENTRAL], the Allied and Complementary Medicine Database [AMED] via EBSCO, and the Cumulative Index to Nursing and Allied Health Literature [CINAHL] via EBSCO), 4 Korean-language databases (Oriental Medicine Advanced Searching Integrated System [OASIS], Koreanstudies Information Service System [KISS], Research Information Service System [RISS], and Korea Citation Index [KCI]), 2 Chinese-language databases (China National Knowledge Infrastructure [CNKI] and Wanfang Data), and 1 Japanese-language database (CiNii). Only randomized controlled trials (RCTs) and quasi-RCTs on HM for CRF will be allowed. The severity of fatigue assessed using a validated tool will be considered as theprimary outcome. The secondary outcomes will include the patients' quality of life, activities of daily life, incidence of adverse events, and total effective rate. Two independent researchers will perform the study selection, data extraction, and quality assessment. RevMan version 5.3 will be used for data synthesis. The methodological quality of the included RCTs will be assessed using the Cochrane Collaboration's risk of bias tool. In the meta-analysis, for dichotomous data and continuous data, risk ratio and mean difference, respectively, will be estimated with their 95% confidence intervals. According to the heterogeneity, either a fixed-effects or a random-effects model will be used.

ETHICS AND DISSEMINATION

Ethical approval is not required because individual patient data are not included. The findings of this systematic review will be disseminated through a peer-reviewed publication or conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42019141660.

The efficacy and safety of Kyung-Ok-Ko on cancer-related fatigue in lung cancer patients: Study protocol for a randomized, patients-assessor blind, placebo-controlled, parallel-group, single-center trial

BACKGROUND

Cancer-related fatigue (CRF) is a major symptom experienced by lung cancer patients receiving chemotherapy and radiation therapy. Since CRF has a multidimensional influence on cancer patients, they may experience physical weakening, a decline in cognitive function, and depression from emotional consequences. Kyung-Ok-Ko is used for improving fatigue or weak physical constitution. It is known to be effective in immune activation, reducing fatigue, and enhancing cognitive function. Although Kyung-Ok-Ko is clinically used for the treatment of CRF, its efficacy and safety against CRF in lung cancer patients are yet to be studied. Therefore, we aimed to investigate the efficacy and safety of Kyung-Ok-Ko.

METHODS

This is a randomized, placebo-controlled, patients-assessor blind, parallel-group, single-center clinical trial. Lung cancer patients with CRF, after termination of chemo or radiation therapies, are randomized in a 1:1 ratio to receive either Kyung-Ok-Ko or placebo for 6 weeks. The primary outcome is Brief Fatigue Inventory (BFI). The secondary outcomes include Visual Analog Fatigue Scale (VAFS), Functional Assessment of Cancer Therapy (FACIT) Fatigue scale, Hospital Anxiety Depression Scale (HADS), Montreal Cognitive Assessment Korean version (MoCA-K), and Korean pattern identification questionnaire. Adverse events are evaluated by Common Terminology Criteria for Adverse Events (CTCAE). All outcomes and adverse events are assessed at the baseline, mid-treatment, post-treatment, and at 1-month follow-up.

DISCUSSION

This study investigates whether Kyung-Ok-Ko can alleviate CRF in lung cancer patients. The results of this study will provide clinical evidence for the application of Kyung-Ok-Ko in the treatment of CRF in lung cancer patients.

TRIAL REGISTRATION

Korean Clinical Trial Registry (http://cris.nih.go.kr; registration number: KCT000666).Trial status: Currently, participant recruitment is ongoing.

Suppression of lung inflammation by the ethanol extract of Chung-Sang and the possible role of Nrf2

Background

Asian traditional herbal remedies are typically a concoction of a major and several complementary herbs. While balancing out any adverse effect of the major herb, the complementary herbs could dilute the efficacy of the major herb, resulting in a suboptimal therapeutic effect of an herbal remedy. Here, we formulated Chung-Sang (CS) by collating five major herbs, which are used against inflammatory diseases, and tested whether an experimental formula composed of only major herbs is effective in suppressing inflammation without significant side effects.

Methods

The 50% ethanol extract of CS (eCS) was fingerprinted by HPLC. Cytotoxicity to RAW 264.7 cells was determined by an MTT assay and a flow cytometer. Nuclear NF-κB and Nrf2 were analyzed by western blot. Ubiquitinated Nrf2 was similarly analyzed following immunoprecipitation of Nrf2. Acute lung inflammation and sepsis were induced in C57BL/6 mice. The effects of eCS on lung disease were measured by HE staining of lung sections, a differential cell counting of bronchoalveolar lavage fluid, a myeloperoxidase (MPO) assay, a real-time qPCR, and Kaplan-Meier survival of mice.

Results

eCS neither elicited cytotoxicity nor reactive oxygen species. While not suppressing NF-κB, eCS activated Nrf2, reduced the ubiquitination of Nrf2, and consequently induced the expression of Nrf2-dependent genes. In an acute lung inflammation mouse model, an intratracheal (i.t.) eCS suppressed neutrophil infiltration, the expression of inflammatory cytokine genes, and MPO activity. In a sepsis mouse model, a single i.t. eCS was sufficient to significantly decrease mouse mortality.

Conclusions

eCS could suppress severe lung inflammation in mice. This effect seemed to associate with eCS activating Nrf2. Our findings suggest that herbal remedies consisting of only major herbs are worth considering.

Epigenetic Approach to Asthma Diagnosed using Korean Differentiation- Category in Traditional Korean Medicine

Asthma is a serious disease around the world. It is caused by genetic and environmental factors. Epigenetics is the study of heritable changes in gene expression without changes of deoxyribonucleic acid (DNA) sequences. The gene expression change is due to methylation on DNA. Traditional Korean Medicine (TKM) uniquely classifies patients with asthma according to their symptoms. The present study is investigated to find a novel epigenetic marker of diagnosis for Korean asthma patients using Korean differentiation syndrome category in TKM. We recruited 62 patients with asthma from departments of respiratory medicine in hospitals. They are classified by symptom diagnosis and questionnaire to the deficiency syndrome (DS) group and excess syndrome (ES) group. And their DNA was extracted from peripheral blood. To investigate novel epigenetic markers on classification by Korean differentiation syndrome category, methylation analysis was performed using next generation sequencing (NGS), Agilent SureSelect Human Methyl-Seq which is a tool from Agilent Technologies company. In analysis of differential methylated epigenetic markers between the DS group and the ES group, total of 8 sites in exon region in [meprin (a cell surface glycoprotein), A5 antigen (a developmentally-regulated cell surface protein), and receptor protein-tyrosine phosphatase mu (MAM) domain containing glycosylphosphatidylinositol anchor 1] (MDGA1) gene were considered to be closely associated with differentiation syndrome category in Korean asthma patients. The methylation within MDGA1 gene could be regarded as an epigenetic candidate marker for Korean differentiation syndrome category in Korean asthma patients.

Oral administration of herbal medicines for radiation pneumonitis in lung cancer patients: A systematic review and meta-analysis

BACKGROUND

Radiation pneumonitis is a common and serious complication of radiotherapy. Many published randomized controlled studies (RCTs) reveal a growing trend of using herbal medicines as adjuvant therapy to prevent radiation pneumonitis; however, their efficacy and safety remain unexplored.

OBJECTIVE

The aim of this systematic review is to evaluate the efficacy and safety of herbal medicines as adjunctive therapy for the prevention of radiation pneumonitis in patients with lung cancer who undergo radiotherapy.

METHODS

We searched the following 11 databases: three English medical databases [MEDLINE (PubMed), EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL)], five Korean medical databases (Korean Studies Information, Research information Service System, KoreaMed, DBPIA, National Digital Science Library), and three Chinese medical databases [the China National Knowledge Database (CNKI), Journal Integration Platform (VIP), and WanFang Database]. The primary outcome was the incidence of radiation pneumonitis. The risk of bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Twenty-two RCTs involving 1819 participants were included. The methodological quality was poor for most of the studies. Meta-analysis showed that herbal medicines combined with radiotherapy significantly reduced the incidence of radiation pneumonitis (n = 1819; RR 0.53, 95% CI 0.45-0.63, I2 = 8%) and the incidence of severe radiation pneumonitis (n = 903; RR 0.22, 95% CI 0.11-0.41, I2 = 0%). Combined therapy also improved the Karnofsky performance score (n = 420; WMD 4.62, 95% CI 1.05-8.18, I2 = 82%).

CONCLUSION

There is some encouraging evidence that oral administration of herbal medicines combined with radiotherapy may benefit patients with lung cancer by preventing or minimizing radiation pneumonitis. However, due to the poor methodological quality of the identified studies, definitive conclusion could not be drawn. To confirm the merits of this approach, further rigorously designed large scale trials are warranted.

A natural infection by the red sea bream iridovirus-type Megalocytivirus in the golden mandarin fish Siniperca scherzeri

An outbreak of a Megalocytivirus infection was found in the golden mandarin fish Siniperca scherzeri during September and October 2016, in Korea. Phylogeny and genetic diversity based on the major capsid protein (MCP) and adenosine triphosphatase (ATPase) genes showed a new strain. Designated as GMIV, this strain derived from the golden mandarin fish was suggested to belong to the red sea bream iridovirus (RSIV)-subgroup I. Additionally, this train clustered with the ehime-1 strain from red sea bream Pagrus major in Japan and was distinguished from circulating isolates (RSIV-type subgroup II and turbot reddish body iridovirus [TRBIV] type) in Korea. The infection level, evaluated by qPCR, ranged from 8.18 × 102 to 7.95 × 106  copies/mg of tissue individually, suggesting that the infected fish were in the disease-transmitting stage. The diseased fish showed degenerative changes associated with cytomegaly in the spleen as general sign of Megalocytivirus infection. The results confirm that the RSIV-type Megalocytivirus might have crossed the environmental and species barriers to cause widespread infection in freshwater fish.

Comparison of mode of failure between primary and revision total knee arthroplasties

INTRODUCTION

Cognizance of common reasons for failure in primary and revision TKA, together with their time course, facilitates prevention. However, there have been few reports specifically comparing modes of failure for primary vs. revision TKA using a single prosthesis. The goal of the study was to compare the survival rates, modes of failure, and time periods associated with each mode of failure, of primary vs. revision TKA.

HYPOTHESIS

The survival rates, modes of failure, time period for each mode of failure, and risk factors would differ between primary and revision TKA.

MATERIAL AND METHODS

Data from a consecutive cohort comprising 1606 knees (1174 patients) of primary TKA patients, and 258 knees (224 patients) of revision TKA patients, in all of whom surgery involved a P.F.C^® prosthesis (Depuy, Johnson & Johnson, Warsaw, IN), was retrospectively reviewed. The mean follow-up periods of primary and revision TKAs were 9.2 and 9.8 years, respectively.

RESULTS

The average 10- and 15-year survival rates for primary TKA were 96.7% (CI 95%,±0.7%) and 85.4% (CI 95%,±2.0%), and for revision TKA 91.4% (CI 95%,±2.5%) and 80.5% (CI 95%,±4.5%). Common modes of failure included polyethylene wear, loosening, and infection. The most common mode of failure was polyethylene wear in primary TKA, and infection in revision TKA. The mean periods (i.e., latencies) of polyethylene wear and loosening did not differ between primary and revision TKAs, but the mean period of infection was significantly longer for revision TKA (1.2 vs. 4.8 years, P=0.003).

DISCUSSION

Survival rates decreased with time, particularly more than 10 years post-surgery, for both primary and revision TKAs. Continuous efforts are required to prevent and detect the various modes of failure during long-term follow-up. Greater attention is necessary to detect late infection-induced failure following revision TKA.

LEVEL OF EVIDENCE

Case-control study, Level III.

High prevalence of betanodavirus barfin flounder nervous necrosis virus as well as red-spotted grouper nervous necrosis virus genotype in shellfish

Using two serially executed PCRs, the discriminative multiplex two-step RT-PCR (DMT-2 RT-PCR) following the detection seminested two-step RT-PCR (DSN-2 RT-PCR), we found a high frequency presence of BFNNV genotype as well as RGNNV in various domestic and imported shellfish. This was definitely different from the previous reports of outbreaks and asymptomatic infection only by the RGNNV genotype in cultured finfish in Korea. Cultivation of NNV entrapped in shellfish was performed successfully by a blind passage. Thus, in an attempt to elucidate the epidemiology of betanodavirus, experiments conducted on 969 shellfish samples concluded that (i) distribution of NNV genotype, especially BFNNV, in shellfish is clearly different from that found in finfish of the world; (ii) unlike RGNNV, which showed a high rate in summer, BFNNV showed no seasonal variation and this result suggests BFNNVs in the marine environment remain fairly constant throughout the year; and (iii) the entrapped virus in shellfish was alive and culturable in vitro. These results are the first report of high level prevalence of in vitro culturable NNV in shellfish, for both BFNNV and RGNNV, which may present a potential risk in transmitting nodaviruses to host species in a marine environment.

Mid-term outcomes and complications of total knee arthroplasty in haemophilic arthropathy: A review of consecutive 131 knees between 2006 and 2015 in a single institute

INTRODUCTION

Although total knee arthroplasty (TKA) in haemophilic arthropathy can reduce severe joint pain and improve functional disability, it is technically demanding.

AIM

To evaluate mid-term outcomes and complications of TKA in haemophilic arthropathy.

METHODS

This study retrospectively reviewed 131 consecutive primary TKAs in a single institute. The mean age was 41.0 years old, and the mean follow-up period was 6.8 years. Clinical and radiographic results were evaluated. Complications were categorized according to the classification system of the Knee Society for TKA complications.

RESULTS

The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score improved from 66.0 to 24.2. The average flexion contracture significantly decreased from 17.3° to 4.7°, but the average pre- and postoperative maximum flexion did not differ (80.9° vs 85.6°, respectively). The average mechanical axis was varus 5.2° preoperatively and valgus 0.3° postoperatively. The coronal positions of the femoral and tibial components and the sagittal positions of these components were within ±3° in 83.2%, 89.3%, 63.4% and 73.3% of cases, respectively. Complications occurred in 17 knees (13.0%): hemarthrosis (n = 7), medial collateral ligament injury (n = 1), stiffness (n = 2), deep periprosthetic joint infection (PJI) (n = 3) and periprosthetic fracture (n = 4).

CONCLUSIONS

The mid-term results of TKA in haemophilic arthropathy were satisfactory in pain relief, improved function and decreased flexion contracture. Bleeding and PJI continue to be major concerns for TKA in haemophilic arthropathy, and risk of periprosthetic fracture must be taken into account for patient education and appropriate prevention.

Effects of herbal medicine for dysmenorrhea treatment on accompanied acne vulgaris: a study protocol for a randomized controlled trial

Background

The incidence of preadolescent acne among women is increasing. Acne deteriorates the quality of life; conventional treatment options are limited and have not been effective against acne, particularly acne associated with menstruation. Despite evidence that acne associated with menstruation abnormalities naturally improves when menstruation recovers to normal, there have only been few studies on the effects of dysmenorrhea treatment on acne. Therefore- we designed this study to assess the effects of gyejibokryung-hwan (GBH) and dangguijagyag-san (DJS), which are widely used in dysmenorrhea treatment, on acne associated with menstruation cycle.

Methods

This is a protocol for a randomized, double-blind, parallel-group, placebo-controlled and multicenter trial. One hundred and sixteen participants with dysmenorrhea accompanied by acne vulgaris will be recruited at three centers and randomized into two groups, the herbal treatment group and placebo group. The participants will receive GBH or DJS based on pattern identification or placebo granules thrice daily for 8 weeks, with an 8-week follow up. The primary outcome will be the mean percentage change in the count of inflammatory acne lesions. The secondary outcomes would be based on dysmenorrhea numeric rating scale, verbal multidimensional scoring system for dysmenorrhea, acne numeric rating scale, investigator’s static global assessment scale of facial acne vulgaris, and safety testing. Adverse events will also be reported.

Discussion

The effects of GBH or DJS used in dysmenorrhea treatment on acne associated with the menstrual cycle will be evaluated. The findings of this trial will provide evidence regarding the effect of herbal medicine in improving acne vulgaris associated with menstruation in women.

Trial registration

Korean Clinical Trial Registry (http://cris.nih.go.kr; registration number: KCT0002259). Date of registration: March 10, 2017

Association Between Secretoglobin Family 3A Member 2 (SCGB3A2) Gene Polymorphisms and Asthma in a Korean Population

Background

Secretoglobin family 3A member 2 (SCGB3A2) plays an important role in secreting lung surfactant protein, which is a downstream target of thyroid transcription factor.

Material/Methods

We investigated whether single-nucleotide polymorphisms (SNPs) of SCGB3A2 gene contribute to susceptibility to asthma. To explore this possible association, 2 promoter SNPs (rs6882292, 659 G/A and rs1368408, −112 G/A) and missense SNP (rs151333009, stop codon) were tested in SCGB3A2 gene in 101 asthma patients and 377 healthy control subjects. SNPStats was used to obtain odds ratio (OR), 95% confidence intervals (CI), and P value adjusted for age and sex as covariables. Logistic regression method in each model (dominant, recessive, and log-additive) was applied to analyze genetic data.

Results

rs151333009 SNP showed a monomorphic genotype. Two promoter SNPs (rs6882292, −659 G/A and rs1368408, −112 G/A) showed significant association with asthma (rs6882292, OR=2.66, 95% CI=1.42–5.01, p=0.0033 in dominant model, OR=2.45, 95% CI=1.33–4.54, p=0.0055 in log-additive model; rs1368408, OR=1.59, 95% CI=1.02–2.49, p=0.041 in dominant model, OR=3.02, 95% CI=1.15–7.90, p=0.03 in recessive model, OR=1.63, 95% CI=1.63, 95% CI=1.12–2.37, p=0.012 in log-additive model).

Conclusions

These results suggest that the promoter SNPs (rs6882292 and rs1368408) of SCGB3A2 gene may contribute to susceptibility to asthma in a Korean population.

A traditional herbal medication, Maekmoondong-tang, for cough: A systematic review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Maekmoondong-tang (MMDT) is a traditional herbal medication widely used to improve cough in Korea, Japan, and China. It is composed of six herbs (Ophiopogonis Tuber, Pinelliae Tuber, Glycyrrhizae Radix, Zizyphi Fructus, Ginseng Radix, and Oryzae Semen).

AIM OF THE STUDY

This study is aimed to systematically review the relevant randomised controlled trials (RCTs) to determine the effectiveness and safety of MMDT for cough.

MATERIALS AND METHODS

Electronic and hand-searching of 7 databases (Cochrane Library, MEDLINE, EMBASE, OASIS, RISS, CNKI and CiNii) was systematically conducted up to February 2015 for RCTs testing MMDT in patients with cough. The primary outcome was cough symptom improvement using cough diary, visual analog scale, or response rate. Risk of bias of the included trials was evaluated with the Cochrane risk of bias assessment tool. The dichotomous data were pooled to obtain a risk ratio (RR) of cough persisting after treatment, with 95% confidence intervals (CI).

RESULTS

Nine RCTs involving 2453 participants were included. The methodological quality was largely poor for a majority of the studies. MMDT reduced the severity of cough by 74% compared with the conventional antitussive medications in various conditions (n=1145; RR of cough persisting after treatment=0.26; 95% CI, 0.19-0.34, I(2)=0%). The addition of MMDT to conventional medication in patients with postinfectious cough significantly alleviated symptoms up to day 5 but the effect was not maintained one week afterwards. For other diseases/conditions including chronic obstructive pulmonary disease, lung cancer surgery, and asthma, the evidence is inconsistent for MMDT/mMMDT for cough. Adverse events appear to be rare but the reporting was poor.

CONCLUSIONS

The current evidence from our systematic review and meta-analysis on MMDT for cough is inconclusive and we propose that rigorously designed, placebo-controlled trials of MMDT should be conducted to establish its place in management of cough.

Efficacy and safety of Maekmoondong-tang for chronic dry cough: a study protocol for a randomized controlled trial

Background

Chronic cough, defined it lasts more than 8 weeks. The symptom is common, but highly troublesome, and it reduces quality of life. Despite much effort to develop a protocol for diagnosis and treatment of chronic cough, it remains problematic to determine its cause. As a result, treatment is often unsuccessful. Thus, there is much interest regarding the use of symptomatic drugs to control chronic cough.

Maekmoondong-tang is widely used in East Asian countries to treat chronic dry cough. Several experimental studies have reported that the herbal medicine has immunomodulatory and antitussive effects. Clinical studies involving Maekmoondong-tang have also been carried out; however, these studies have involved treating various diseases as a whole rather than chronic cough itself. Thus, we aim to evaluate the efficacy and safety of Maekmoondong-tang in chronic dry cough patients with a randomized controlled trial.

Methods/Design

This study is designed as an exploratory, single-center, placebo-controlled, double-blind, randomized, parallel group clinical trial. Patients with dry cough that has lasted more than 8 weeks will be recruited, after a 1-week run-in period, and randomly allocated to either the Maekmoondong-tang treatment group or the placebo group. The patients will receive Maekmoondong-tang or placebo granules 3 times daily for 4 weeks, with a 2-week follow-up. The primary outcome is a 10-point cough diary that will be recorded on a daily basis. The secondary outcomes comprise a cough visual analog scale, the Leicester Cough Questionnaire (Korean version), the Pattern Identification for Chronic Cough Questionnaire, biomarkers, safety testing, etc. Adverse events will also be reported.

Discussion

This trial will assess the efficacy and safety of Maekmoondong-tang in chronic dry cough.

Trial registration

Korean Clinical Trial Registry (http://cris.nih.go.kr; registration number: KCT0001646). Date of registration: October 5 2015

Inhibitory effects of Cheongsangbangpoong-tang on both inflammatory acne lesions and facial heat in patients with acne vulgaris: A randomized controlled trial protocol

Background

Due to increasing interest from acne patients concerned about the side effects associated with conventional therapies, complementary and alternative medicine (CAM) has been suggested as a new therapeutic modality for acne vulgaris. Herbal medicine is one of these CAM treatments. Cheongsangbangpoong-tang (CBT) is a common herbal formula used in patients with acne vulgaris in the clinical practice of Korean Medicine (KM). However, despite the common use of CBT in clinical practice, the current level of evidence is insufficient to support an inhibitory effect of CBT on inflammatory acne lesions and facial heat. Therefore, this study was designed to assess the inhibitory effect of CBT on both inflammatory acne lesions and facial heat.

Methods/design

A randomized, double-blind, parallel-group, and placebo-controlled trial will be conducted. Fifty-six participants with acne vulgaris will be randomized into one of two groups: the CBT or placebo groups. After randomization, participants will be prescribed either CBT or placebo three times a day at a dose of 5 g after meals for 8 weeks. The following outcome measurements will be used in the examination of subjects: the mean percentage change and the count change of the inflammatory and non-inflammatory acne lesions, the temperature of facial points on digital infrared thermal imaging (DITI), serum cortisol, serum dehydroepiandrosterone-sulfate (DHEA-S), visual analogue scale (VAS), investigator global assessment (IGA), and severity score on the Korean Acne Grading System (KAGS) from baseline to the end of the trial.

Discussion

This trial will provide evidence regarding the inhibitory effect of CBT on inflammatory acne lesions and facial heat. The findings of this trial may have important implications for the more widespread use of CBT for the treatment of acne vulgaris.

Trial registration

The trial is registered with the Clinical Research Information Service (CRiS), Republic of Korea: KCT0001468.

Effects of Chung-Pae Inhalation Therapy on a Mouse Model of Chronic Obstructive Pulmonary Disease

Chung-pae (CP) inhalation therapy is a method frequently used in Korea to treat lung disease, especially chronic obstructive pulmonary disease (COPD). This study investigated the effects of CP inhalation on a COPD animal model. C57BL/6 mice received porcine pancreatic elastase (PPE) and lipopolysaccharide (LPS) alternately three times for 3 weeks to induce COPD. Then, CP (5 or 20 mg/kg) was administered every 2 h after the final LPS administration. The effect of CP was evaluated by bronchoalveolar lavage (BAL) fluid analysis, histological analysis of lung tissue, and reverse transcription polymerase chain reaction analysis of mRNA of interleukin- (IL-) 1β, tumor necrosis factor- (TNF-) α, IL-6, and tumor growth factor- (TGF-) β. Intratracheal CP administration reduced the number of leukocytes and neutrophils in BAL fluid, inhibited the histological appearance of lung damage, and decreased the mRNA levels of the proinflammatory cytokines IL-1β, TNF-α, IL-6, and TGF-β. Intratracheal CP administration effectively decreased the chronic inflammation and pathological changes in a PPE- and LPS-induced COPD mouse model. Therefore, we suggest that CP is a promising strategy for COPD.

Identification of metabolites produced by Phanerochaete chrysosporium in the presence of amlodipine orotate using metabolomics

Pharmaceuticals are very useful in treating human diseases but they are excreted to the environment sometimes in their original form or as byproducts of human metabolism. Pharmaceuticals and their metabolites have been proven by studies to be harmful to non-target ecological species and may be persistent in different water matrices. In this regard, there is an emergent need to eliminate these compounds to prevent their adverse effects on aquatic species. Biodegradation using white-rot fungi is a promising technology for the removal of recalcitrant compounds; however, products of fungal biodegradation can also be detrimental. In this novel study, we evaluated the ability of Phanerochaete chrysosporium to degrade amlodipine, an anti-hypertensive drug which was recently found in water systems. Analysis of amlodipine metabolites was done using quadrupole time-of-flight liquid chromatography mass spectrometry after the degradation set-up of 120 hours. Pharmaceutical degradation was seen using triple quadrupole liquid chromatography tandem mass spectrometry. Ninety-two significant metabolites (P-value ≤ 0.05) were significantly expressed after false discovery rate adjustment at a significance threshold of q = 0.05. Pyridine derivatives which were identified from samples became the basis of the proposed degradation pathway of amlodipine in this study.

Treatment of distal femur fractures with locking plates: Comparison of periprosthetic fractures above total knee arthroplasty and non-periprosthetic fractures

The purpose of the present study was to compare the results and plate fit of periprosthetic and non-periprosthetic distal femur fractures fixed with locking plates. Twenty-one periprosthetic fractures above a TKA and 27 non-periprosthetic fractures were retrospectively reviewed. The primary healing rate, bone union time, clinical and radiographic results, complications, and additional surgeries were compared between the two groups. The quality of the plate fit on the bone was also compared. There were no differences in the primary healing rate, bone union time, clinical and radiographic results between the two groups. The incidence of overall complication and additional surgeries did not differ (3/21 vs. 5/27, 1/21 vs. 4/27). Plate fit trouble was observed more frequently in periprosthetic fractures (10/21 vs. 1/27, p = 0.004). Fixation of distal femur fractures with locking plates provided satisfactory results with a low risk of complications and additional surgeries in both periprosthetic and non-periprosthetic fractures.

The prognosis and treatment of primary thyroid cancer occurred in breast cancer patients: comparison with ordinary thyroid cancer

PURPOSE

Due to the increased prevalence of thyroid cancer, it has been frequently detected in breast cancer patients recently. The aim of this study was to evaluate the clinicopathologic characteristics of thyroid cancer in breast cancer patients with respect to prognosis and treatment.

METHODS

From August 1998 to September 2012, 101 breast cancer patients were diagnosed with thyroid cancer (BT group). One hundred ninety-three female patients with a thyroid malignancy that underwent thyroidectomy in 2008 were recruited as controls (oT group). The clinicopathologic results of these two groups were compared.

RESULTS

Patients were older (51.40 vs. 47.16, P < 0.001), mean tumor size was smaller (0.96 cm vs. 1.43 cm, P < 0.001), and extrathyroidal extension was less common in the BT group. In both groups, papillary thyroid carcinoma was the most common type of thyroid malignancy. T and N classifications of thyroid cancer were less severe in the BT group, but group TNM stages were similar. Endoscopic thyroid surgery was performed in 12.9% of patients in the BT group and in 6.7% of patients in the oT group. Postoperative radioactive iodine ablation was performed less often in the BT group (P < 0.001). Group recurrence rates were not significantly different.

CONCLUSION

Thyroid cancer in breast cancer patients was diagnosed at earlier status than ordinary thyroid cancer. However, the prognosis of thyroid cancer in breast cancer patients was not superior to that in patients with thyroid cancer alone. Radioactive iodine ablation was performed less often and endoscopic surgery could be performed in breast cancer patients.

Efficacy and safety using autotransfusion system with postoperative shed blood following total knee arthroplasty in haemophilia

The purpose of this study was to evaluate the efficacy and safety of postoperative wound drain salvage and autotransfusion system in haemophilic patients undergoing elective total knee arthroplasty (TKA). No literature exists on reinfusing drained blood in patient with haemophilia undergoing TKA. Eighty-eight knees of 66 patients received cemented TKA due to end-stage haemophilic arthropathy (group I; with autotransfusion in 59 knees, group II; without autotransfusion in 29 knees). In group I, the postoperative shed blood was transfused within 6 h after surgery. The amount of blood drainage and reinfused blood, rate and amount of allogenic transfusion, postoperative change of haemoglobin level, prothrombin time (PT) and activated partial thromboplastin time were analysed. The mean postoperative blood drainage was 932 ± 479 mL in group I and 830 ± 492 mL in group II (P > 0.05). The mean volume of blood reinfused was 530 ± 265 mL in group I. Allogenic transfusion was needed in six knees (10.2%) of group I and eight knees (27.6%) of group II (P = 0.036). The mean volume of allogenic transfusion was 480 ± 49 mL in group I and 1041 ± 691 mL in group II (P > 0.05). Changes of all the laboratory results before and after TKA showed no statistically significant difference except PT was prolonged in group I (P = 0.008) at postoperative day 1. Moreover, there was no significant complication related to either reinfusion or allogenic transfusion in both groups. This study showed that reinfusion of drained blood is a simple, safe and efficacious method in patients with haemophilia undergoing TKA.