The Blue Vanguard Vol.19

Yonsei Student Pharmacist

THE

BLUE

VANGUARD

MAIN ARTICLES Interviews

Byeong Hoon Lee, External Affairs & Regulatory Affairs Department at Celltrion

Pharmaceuticals Microneedle drug delivery

International Issues

E-mart, on the Border of Noise-Marketing and Tyranny

2021

JULY Vol.19

Editor's note

Gee Yoon Zoo

Three semesters have passed ever since the first outbreak of COVID-19. A lot of things have changed since then, but the one thing that did not change is Blue Vanguardians’ dedication to deliver diverse pharmaceutical information that are useful in our daily lives.

The main articles of this issue involve the following: an interview with the External and Regulatory Affairs Department at Celltrion, an article on pharmaceuticals such as microneedle drug delivery system, and an article on national issues such as e-mart. Along with these articles are equally interesting and informative articles from column, international issues, and life issues, so be sure to not miss out on them as well.

I thank all Blue Vanguardians for their hard work on writing such great articles and designing the magazine during the busy school semester. It is a shame that most of us have not met each other yet, but I really hope that we do one day once the pandemic is over. Until that day comes, I hope everyone stays safe. I would also like to thank our subscribers for reading and supporting our magazine. Blue Vanguardians have put in great effort and care in writing their articles, so I really do hope you enjoy our 19th issue.

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1) Interview • Byeong Hoon Lee, External Affairs & Regulatory Affairs Department at Celltrion : 4-5p

2) Pharmaceuticals • Microneedle drug delivery : 6-7p • We Need to Talk About the CAR-T Cell : 8-9p • Cold Sore, Who Are You? : 10-11p • Clinical Trials in Children : 12-13p

3) Column • Sunscreen: A Friend or a Foe? : 14-15p • Supplement Suggestion for Homebodies : 16-17p • Ketogenic Diet : 18-19p • Solidarity in Health: What We need Right now : 20-21p

4) National Issues • e-mart, on the Border of Noise-Marketing and Tyranny : 22-23p

5) International Issues

• Can Climate Change Trigger New Diseases Outbreak? : 24-25p • Monoclonal Antibody Treatments for COVID-19 : 26-27p

6) Life issues • Allurements of Carbohydrates: Importance of Nutrition Facts Label : 28-29p • Do You Own Your Mind? : 30-31p • Burnout Syndrome: A Tired Society : 32-33p

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INTERVIEW

Interview with Byeong Hoon Lee, External Affairs & Regulatory Affairs Department at Celltrion YoonZoo Gee

I

yzgee@yonsei.ac.kr

n March of 2021, the Blue Vanguardians interviewed Byeong Hoon Lee, the 3rd graduate of Department of Pharmacy at Yonsei University and an employee at the external affairs and regulatory affairs department at Celltrion. The interview was conducted virtually on Zoom where he gave honest and sincere answers to not only interview questions, but also to all individual questions on the spot.

Thanks to him, we learned a lot about what we have to prepare to work in a pharmaceutical company and what it would be like to work in the external affairs and regulatory affairs department.

Q: Could you please introduce yourself and your department?

After graduating from Yonsei University and completing military service, I have been working in the external affairs and regulatory affairs department at Celltrion for a year and a half. The department is further subdivided into two teams: the global regulatory affairs and domestic regulatory affairs. I belong to the latter, so our team deals with regulatory affairs that occur in South Korea by communicating with the Ministry of Food and Drug Safety (MFDS).

The external affairs and regulatory affairs department is essentially the bridge between regulatory authorities and pharmaceutical companies. We administrate all stages from drug development, clinical trials, to post-market surveillance, but we mainly focus on the drug approval process.

One of the biggest tasks of our team is managing the drug approval processes for biopharmaceuticals developed and launched by Celltrion. These involve Remsima, Herzuma, Truxima, Regkirona, and Yuflyma. Also, we are responsible for variation approval when adjustments are made during and after Investigational New Drug (IND) approval. Another task of our team is to assess whether any changes have permit impacts. We do this because such changes can affect the drug’s approval.

Q: How are drugs generally approved in South Korea?

Before drugs are approved, they go through complex processes of development. The first step is the screening of starting materials to see whether or not they can be developed into drugs. Then, research is conducted to see if any problems arise when the manufacturing unit is scaled up for commercial production. If there are no problems, clinical trials are conducted to evaluate safety and efficacy. All non-clinical and clinical data are then sent to the MFDS for the drug to be approved. The biopharmaceutical drugs of our company usually take approximately eight to ten months to be approved.

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Q: When national emergencies emerge, like COVID-19, are there any changes made in the drug approval process?

The drug approval process itself does not change, but some departments are specifically dedicated to respond to national emergencies like COVID-19. The names of these departments are Expedited Review Division of Medicine and Medical Devices and the Pre-Submission Consultation Division. The Expedited Review Division of Medicine and Medical Devices speeds up the drug approval process during national emergencies by having dedicated personnel review the data more quickly than usual. In addition, pharmaceutical companies can consult with the PreSubmission Consultation Division before they officially file an approval for a drug to see if there is sufficient and appropriate data. These divisions are useful especially when an immediate response is required as in the case of a COVID-19 treatment.

Moreover, the drug approval process can be shortened through conditional approval. This allows a drug to be approved when data cannot be physically gathered at the time of an emergency. However, pharmaceutical companies have to eventually submit them to the MFDS after the third phase of clinical trials.

Q: In which departments do pharmaceutical students usually work in Celltrion?

Many pharmaceutical students work in departments that manage clinical trials. I think this is because pharmaceutical students have a chance to experience the clinical field in their fifth and sixth years which is when they start thinking about their career. Many pharmaceutical students also work in the external affairs and regulatory affairs department. Since Celltrion is one of the biggest biopharmaceutical companies in South Korea that does global business, the department is divided into smaller teams such as global/domestic, clinical, and quality RA. Additionally, pharmaceutical students work in departments that involve Post Market Surveillance (PMS) and Pharmacovigilance (PVG). These departments research and deliver data regarding adverse effects and patient complaints to the MFDS.

Q: Are there any advice you would like to give for pharmacy students who want to work in external affairs and regulatory affairs?

One advice I would like to give those who want to work in this field is to develop communication skills. Like I said previously, the external affairs and regulatory affairs department acts as a bridge between pharmaceutical companies and the MFDS. It has to scientifically justify and persuade the MFDS in consideration of the cost and time for such information to be produced. Being meticulous is also very important. Even the slightest mistake of typing in a wrong single digit can lead to the production, sale, and administration of an inadequate drug. This is in fact illegal and may lead to administrative dispositions.

Overall, the interview allowed us to indirectly experience the work being done at the external affairs and regulatory affairs department. We also got great advice regarding curricular and extracurricular activities. This was especially helpful considering that we have not had a chance to meet with our professors and seniors due to COVID-19. B

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PHARMACEUTICALS

Microneedle drug delivery Aran Kim

dreamct717@naver.com

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ext-generation drugs have been developed to replace existing drugs. In fact, an extensive research has been done on a “Drug Delivery System (DDS)” to administer drugs to patients more effectively. Among various next-generation DDSs, this article will discuss microneedle drug delivery, which uses fine needles to inject drugs into patients. Microneedle drug delivery system is one of the top 10 promising technologies selected at the 2020 World Economic Forum. Microneedle drug delivery system is a transdermal drug delivery system that utilizes microscopic needles within hundreds of micrometers of length to pass through the stratum corneum of the skin and deliver effective ingredients into the skin. This is drawing attention as a next-generation DDS that can maintain syringe efficacy, but can eliminate injection phobia using a patch. The microneedle drug delivery system is expected to have a significant impact on the biotechnology industry within five years.

1. Types of microneedles There are three main types of microneedle. The first type is a solid microneedle, which is the major form in dermatological procedures. People roll the solid needle over the face and apply effective ingredient on top of the small cut. However, there are limitations because the amount of medication injected is not constant and very small due to rapid skin recovery.

The second type is a coated microneedle. This is a form of medicine applied to the surface of the needle. When the needle is stabbed into the skin, effective amount of drug is injected into the body fluid. Although the amounts of drugs injected is constant compared to that solid microneedle, they are not used much because of the limited doses of drugs that can be delivered.

The third type is a dissolving microneedle. In this case, the needle is a water-soluble polymer that contains an active substance. When the dissolving microneedle is poked into scallion, the microneedle melts in the body fluid and disappears, leaving only effective ingredients. This can be expected to have a continuous drug effect by simply attaching it to the appropriate area.

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2. Applications of microneedles What are some medicines that are being developed with microneedle DDS? One example is an osteoporosis treatment which is undergoing phase 2 clinical trials at 3M. This treatment involves an artificial form of parathyroid hormone called Abaloparatid, which is expected to be used mainly for postmenopausal women’s treatment of osteoporosis. Corium is also famous for developing percutaneous patch agents, which is undergoing phase II clinical trials for the treatment of osteoporosis. In addition, Zosano Pharma, the world’s most advanced technology company in the microneedle industry, has applied for the approval of a new drug for a patchy acute migraine treatment called Zolmitriptan. Among domestic companies, Raphas is one of the leading companies in the new DDS field. Raphas has its own technology called DEN, a patented technology developed by Professor Hyeong-il Jeong of the Department of Biotechnology at Yonsei University. Den is a technology that allows rapid manufacturing of microneedles in less than five minutes without overheating. Raphas is currently co-developing Donepezil using microneedles. Ingredient transfer rate is high because the ingredient solidified with the microneedle is effectively dissolved into the skin.

It is also expected that there will be no skin irritation due to its short attachment time and narrow injection area.

Microneedles may be good alternatives to oral Donepezil for old patients with severe dementia who often struggle to take oral medication.

3. The advantages and challenges of microneedle There are many advantages of microneedles. First, it enables effective injection with less pain than injection agents.

As a result, it can be a good alternative treatment for patients with injection phobia. Additionally, the administration method is simple as the drug just needs to be attached to the appropriate location. Finally, microneedle vaccines significantly reduce the costs for storage and distribution. The costs of transporting fluid-type vaccines to developing countries via frozen transport routes is more expensive than the costs of securing social infrastructure and hiring professionals to make the vaccines. Such problem can be solved by adopting a DDS using microneedle.

As mentioned earlier, microneedle is one of the top 10 promising technologies. Although it is most frequently used in the cosmetic industry as of today, it is expected to be used in more diverse fields if ongoing clinical trials of microneedle drug delivery end well. In an era where infectious diseases such as COVID-9 newly emerge, transporting vaccines with low cost and high stability is a huge challenge. Recently, many people suffered from problems involved with the distribution of vaccines in Korea. A good alternative to solve this situation would be the use of microneedle drug delivery. B

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PHARMACEUTICALS

We need to talk about the CAR-T cell

O

Heeyoun Yang

hyyang11@yonsei.ac.kr

ne-Shot, One kill. Unfortunately, that’s not enough to fight cancer. It’s because while one cancer cell is killed, other cancer cells proliferate into two or more cells. Then the size of the population becomes one less than twice the original population. Nowadays, humans are still in the fight against cancer. Cancer cell shows abnormal cell growth with mobility to invade almost every part of our body. However, if you know your enemies and know yourself, you will not be imperiled in a hundred battles’. As the saying goes, scientists have figured out the various characteristics of cancer cells, such as their commonly expressed proteins. And for real, scientists have come up with a treatment by studying our enemies and ourselves. The key of the therapy is T cell, our small bodyguard, which is artificially engineered to specifically attack cancer cells.

Let’s start with the T cell.

Humans spend their entire lives under numerous threats. They become powerless in front of huge threats such as avalanches and earthquakes. However, they do so even in front of small-sized ones. Bacteria and viruses get into the human body without being notified and cause great harm. Just as people have developed techniques to detect and prepare for natural disasters, the human body has established a complex system to detect and defeat those small invaders. It is called the ‘Immune system’ which can be roughly divided into innate and adaptive immunity.

Adaptive immunity, also known as acquired immunity, works along with innate immunity and creates immunological memories to respond more effectively against the next attacks of the same invaders. The two main cells playing an important role in acquired immunity are ‘B cells’ and ‘T cells’. B cells are involved in the humoral immune response, producing antibodies against the antigens. Meanwhile T cells are involved in cell-mediated immune response. Some T cells kill the infected cells directly, while others produce signals to enhance the immune systems. In this process, the antigens on the surface of target cells are recognized by proteins on the surface of T cells. The direct signal promoted by the surface proteins, which are called T-cell receptors, (shortly ‘TCRs’) stimulate that process. This system also works against some mutant cells such as cancer cells which harm the body by endless proliferation. And that is the point where scientists paying their attention.

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Then what is the CAR-T cell?

The full name of CAR-T cell is Chimeric Antigen Receptor T Cell. As its name suggests, it is a T cell. However, it is a special T cell that is genetically engineered. It expresses TCRs with modified antigen-binding sites on its surface.

The artificial receptor proteins are also called ‘Chimeric Antigen Receptors (CARs)’, ‘chimeric immunoreceptors’, ‘chimeric TCRs’, or ‘artificial TCRs’. Any protein that scientists want can be the ligand of CARs, including the new proteins commonly expressed on cancer cells but not on normal cells. The CAR-T cell specifically binds to those proteins and kills the cancer cells. The commercialization of CAR-T cells will make it easier to selectively kill cancer cells with higher effectiveness and fewer side effects. CAR-T cell engineering process is simple. The first step is to extract the patient’s white blood cells from the patient’s body or another healthy person (donor) through a process called ‘leukapheresis’. Then the extracted white blood cells go through some steps to inject a new gene coding CAR into them. They are proliferated, purified, and transduced via vector carrying the CAR gene. Recently the gene-editing tool CRISPR/Cas9 has been widely used in the genetic engineering process. Then, the modified cells are put back into the patient who has undergone lymphodepletion chemotherapy. Lymphodepletion chemotherapy is done before the introduction of the CAR-T cells because the decreased number of cells stimulates the release of factors promoting the expansion of cell population. This leads to the active proliferation of introduced CAR-T cells. Then it’s time for CAR-T cells to work!

CAR-T in the real world: KYMRIAH

On March 5th, 2021, the Ministry of Food and Drug Safety approved KYMRIAH of Novartis, otherwise known as tisagenlecleucel (Tis·agen·le·cleu·cel). It was approved for Diffuse Large B cell Lymphoma (DLBCL), when a recurrence and non-conformity of systemic therapy treatment occurs at least twice. It also can be used for pediatric Acute Lymphoblastic Leukemia (pALL), when re-permittion, secondary recurrence or non-compliance occurs after implantation. KYMRIAH is the first-ever FDA-approved (on Aug 30th, 2017) CAR-T cell therapy and a one-time treatment of CAR-T cell immunotherapy that uses CD19 on cancer cells as an antigen. CD19 is a B-lymphocyte antigen, which is a biomarker for normal and neoplastic B cell as well as follicular dendritic cells. Thus, CD19 has been used to diagnose cancers that arise from not only these types of cells, but also B cell lymphomas, ALL, and chronic lymphocytic leukemia (CLL). The CAR of KYMRIAH contains a 4-1BB costimulatory domain and a CD3ζ intracellular signaling domain. The 4-1BB costimulatory domain is responsible for enhancing the expansion and persistence of KYMRIAH. The CD3ζ intracellular signaling domain is critical for initiating T- cell activation and antitumor activity.

But still, there are adverse reactions, like all other treatments. The most common ADRs are cytokine release syndrome, hypogammaglobulinemia, infections-pathogen unspecified, pyrexia, decreased appetite, etc. Accordingly, CAR-T should be administered with cautious monitoring for patients under appropriate conditions.

Where are we going then?

So far, two types of CAR-T treatments are on the market: KYMRIAH and YESCARTA of Kite Pharma, which FDAapproved after two months of KYMRIAH. As of April 2018, a total of 467 clinical trials of CAR-T treatments were conducted worldwide. The global CAR-T treatment market is expected to grow 53.9% from 84.4 billion KRW in 2017 to 9.7 trillion KRW in 2028. In the Republic of Korea, BioMed, AbClon, Curocell, Green Cross Cell have also entered the CAR-T treatment market. Nevertheless, the Republic of Korea is still a barren land for CAR-T treatments. The industrial environment, which is hard to secure key materials such as viral vectors and enter the clinical trial quickly, is considered a problem. To keep pace with fast-developing pharmaceutical technologies and drug market, we need to develop rapid preparation and adequate coping skills. Or we’ll fall behind. B

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PHARMACEUTICALS

Cold Sore, Who Are You?

A

Donghwan Lee

donglee1009@naver.com

few months ago, I was working as an intern in a laboratory while staying in the school dormitory. One day, I found a pimple on my philtrum and could not bear to squeeze it. Pop! That was really satisfying. However, few days later I got some blisters on my philtrum, and I went to see a doctor. The doctor said “It is just a cold sore.

Blisters may come out when you get tired or lack of nourishments”. Wow, doctor, how did you know my condition?

Anyway, I took pills and applied ointment for about two weeks and got better. So, what is a cold sore?

1. What is a cold sore?

A cold sore is usually caused by viral infections that make blisters around the mouth, lips and sometimes nose or neck. It causes burning, itching and sometimes enlargement of lymph nodes, accompanying fever and muscle aches.

Symptoms can be divided into 8 stages. The first stage is the ‘Latent’ stage. This stage shows no symptoms, because viruses are not active in this stage; they are just getting some rest in your body.

The second stage is the ‘Prodromal’ stage. Viruses do not make blisters yet, but they cause itching and reddening around the mouth or other skins. It may last for a few hours or even a few days.

The third stage is the ‘Inflammation’ stage. Viruses try to make some movement during this stage and causes inflammatory responses which makes the swelling and reddening. Then blisters come out with fluid in them. This is the beginning of the ‘Pre-sore’ stage. It surely is painful and itchy, but not as much as the next stage called ‘Opening lesion’ stage. In this stage, blisters pop and turn into ulcers. Because of the open scars, they are contagious. After that ‘Crusting’ stage begins, and everything falls into normal place during ‘Healing’, ‘Post-scab’ stages.

2. Herpes simplex virus, the culprit of the cold sore Then what causes this annoying cold sore? The culprit is usually Herpes simplex virus type 1 (HSV-1). You might think ‘Herpes? Isn’t it a sexually transmitted disease (STD)? Then is cold sore also a STD?’. Well, the answer is YES, but NO. There are many kinds of viruses in the Herpesviridae family, and Herpes simplex is one of them. Herpes simplex can be subdivided into two types: Herpes simplex virus-1 (HSV-1) and Herpes simplex virus-2 (HSV-2). HSV-1 usually causes the cold sore, while HSV-2 causes genital herpes, a sexually transmitted disease. This difference may come from where the viruses reside in. Both HSV-1, and 2 can have a latent period, but they reside in different parts of our body.

HSV-1 usually resides in trigeminal ganglia, a sensory nerve that is positioned in the face. On the other hand, HSV-2 resides in the sacral ganglia, which is positioned in pelvis.

The transmissions of these viruses are usually made through the contact of an already infected carrier. HSV-1 can be transmitted by oral-to-oral contact or saliva and sores around the mouth. Also, even though without a symptom, HSV-1 can be transmitted to the others. You can be infected by mother’s kiss, lover’s kiss, or any kind of physical contacts. It

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is estimated that 67% of people under age 50 are infected by HSV-1, in 2006, by World Health Organization (WHO).

HSV-2 is usually transmitted by genital-to-genital contact, and that is why it is considered a STD. It was estimated that 13% of people aged 15 to 49 years were infected in 2016, by WHO. Although the prevalence is not as high as HSV-1, it can be more dangerous. WHO says ‘HSV-2 infection increases the risk of acquiring a new HIV infection by approximately three-fold’, and can lead to bad situations when it comes to people who have both HSV-2 and HIV. In summary, the main culprit of cold sore is HSV-1, which is usually not considered a STD (although it can also cause genital herpes), and resides in ganglia without causing any trouble, waiting for the right time to make trouble.

3. How can we overcome this annoying disease?

As pharmacists, you might wonder how we can treat this horrific disease. In fact, the cold sore can be healed without any treatment. However, we can use medicines to relieve the pain and suppress the sores.

Antiviral therapy is the most common way to treat the cold sore. The main medicines are acyclovir, famciclovir, and valacyclovir. They block the viral polymerase so that viruses cannot be reproduced. Also, these medicines need to be phosphorylated by the thymidine kinase, that viruses carry, to be activated. Thus, the uninfected cells can still use DNA polymerase.

As for oral agents, it is suggested that 400mg acyclovir should be taken three times a day for five days. Famciclovir should be taken 750mg twice a day for one day or only once with 1500mg dose. Valacyclovir should be taken twice a day for one day with 2g dose. The therapy is recommended to start as early as possible, no longer than 48 hours after the symptoms occur. Although no studies have been done on which one of these three agents is better, it is known that using high-dose famciclovir and valacyclovir for one day increases the compliance of the patient. Moreover, these three oral therapies have shown prominent healing effect in placebo-controlled trials.

Even though the acyclovir can be applied on the sores as a cream, it seems to be a less effective way to treat the cold sore. Some studies show that although acyclovir can reduce the duration of symptoms, the reduction was smaller than the oral therapy showed. Also, one of the biggest problems of the topical therapy is that it should be applied five times a day. (Five times a day is not an easy way to comply with. I have tried, but never ever could make 5 times application.)

Thus, ‘UpToDate’, a medical site that shows evidence-based clinical decisions, says “we do not use topical antivirals, since topical therapy must be administered multiple times per day and is less effective than oral antiviral therapy”.

4. Conclusion Now we know what a cold sore is and how to cure it. It is usually caused by Herpes simplex virus type 1, which is different from the virus that usually causes genital herpes, and we can treat it with antiviral agents. Also, to prevent this annoying disease, we need to keep our body healthy, so that viruses in our body cannot be activated. I wish you never catch a cold sore like I did! B

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Clinical trials in children SangHee Lee

N

idshannon@yonsei.ac.kr

ow that vaccination against COVID19 has started, when will the vaccine be available for kids? Maybe it will take some time. Clinical trials in children must be carried out for vaccines to be available to kids. Children are not just small adults. Pediatric pharmacokinetics is very different from that of adults as it can be slower or faster depending on the development stage. Also, organs of children grow at different rates. For example, the kidney is as mature as that of adults after one year of age, but the brain grows throughout childhood. Due to these differences, clinical trials in children are essential for a drug to be approved for its safety and effectiveness.

Reality of clinical trials in children According to a research, more than 70 percent of the drugs used in pediatric clinical sites in South Korea are off-label used. This means that most of the drugs used in pediatric sites lack pediatric clinical trial data. Do you remember the sudden death of infants at Ehwa U. Mokdong Hospital a few years ago? The culprit of the death was the contaminated injectable emulsion named ‘smoflipid’. Pediatric Smoflipid is an off-label usage. However, this drug is widely used in South Korea and Europe because it is an essential treatment for premature babies or intensive care neonates, although its safety and validity have not been confirmed for pediatrics. Smoflipid is not sold in small volumes because it is not approved for pediatrics. The smallest capacity is 100ml, but premature babies only need about 15ml, so 85ml left needs to be thrown away. Instead of throwing it out, Ehwa hospital subdivided it to prevent wastes which led to a terrible accident. Still, a lot of off-label used drugs in pediatric clinical sites are facing the same problem.

Timing of clinical trials in children When should clinical trial in children start? The timing of clinical trials in children varies depending on the type of disease. For diseases that occur mostly in children, or pediatric-specific diseases, pediatric trials are conducted from the beginning. For example, respiratory distress syndrome is a neonatal-specific condition; Clinical trials can be conducted entirely in children without any safety database in adults. If the drug treats fatal diseases that can occur both in adults and children, pediatric trials start as soon as stability and validity are confirmed during the clinical trial in adults. It is considered as an urgent situation as the disease is severe. For drugs that treat common diseases, pediatric trials begin after the later phase of the clinical trial in adults or after the post-marketing monitoring. Since many clinical trials are discontinued in phase1 and phase2, it can minimize unnecessary drug exposure to children

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Difference with clinical trials in adults Then, what is different with clinical trials in adults? Since children are physiologically and socially different from adults, there are many differences with clinical trials in adults. First, the size of observation group should be larger.

Unlike other age groups, children, especially neonates, show large variations in absorption, distribution, metabolism, and excretion, hence there are large differences between and within individuals. The size of the group should be large enough to reflect its variability, dose per weight (mg/kg) should be conservatively determined. Second, safety assessments should be made in long term. Even if drug toxicity affects a child’s development, it might not respond in a short period. Therefore, children should be monitored until they are mature enough. In addition, there are differences in sampling methods in pharmacokinetic studies. In a typical pharmacokinetics study, a relatively small group of people take drugs repeatedly. Enough blood or urine samples are taken frequently for pharmacokinetic analysis. However, this is not suitable for children. It is difficult to establish safety for repeatable drug dosage in children since frequent blood collection will be a big stress for them. Thus, blood should be collected less frequently in a bigger groups than in adult clinical trials. The amount of blood collected should also be minimal, so the protocol must specify the amount of blood collected.

Due to these differences, clinical trials of children are difficult. The size of the observation group is larger, the monitoring term is longer, and sampling methods are more difficult, but the target group of pediatric drugs which makes this process cost-ineffective is much smaller than that of adults. Furthermore, there is a negative perception of conducting clinical trials in children, which makes recruiting more difficult. Because children are more vulnerable and need protection, additional protocols for legal protection procedures and stress management should be submitted to the clinical trial review committee. These problems make pharmaceuticals reluctant to precede clinical trials in children, resulting in many off-labeled usages in pediatrics.

Conclusion While the clinical trial in children is important for better treatment and reducing side effects, there are many practical problems. Therefore, the government needs to give more attention and support to pediatrics clinical trials. Also, it is necessary to improve the perception of pediatric clinical trials. Even though there are many negative perceptions, if clinical trials are not conducted, more children may be at greater risk because of off-labeled usage. When these problems are solved, true evidence-based treatments can be achieved in pediatrics. B

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COLUMN

Sunscreen: a friend or a foe?

Okyoon Kim

okyoonkim@gmail.com

S

unlight is important. It helps our bodies to produce vitamin D and to adjust our circadian rhythm and mood.

Like anything, however, too much sunlight damages our health. Prolonged exposure to sunlight can lead to consequences from a light sunburn to life-threatening skin cancer. Therefore, to save our skin from the potetial carcinogen, applying sunscreen is essential. Despite the importance of sunscreen, there are numerous of myths regarding its effectiveness and safety. Some even claim that sunscreen may be the cause of skin cancer. Adding onto the growing confusion, in 2019, the Food and Drug Administration (FDA) removed 14 of the 16 chemicals that compose sunscreens from its GRASE (generally accepted as safe and effective) category. So, what is the truth?

The Darkside of Sun Exposure Sunlight reaching our skin is composed of ultraviolet A (UVA) rays and ultraviolet B (UVB) rays. Among them, approximately 95% are UVA rays which cause wrinkles, photoaging, and age spots. The other 5% are UVB rays, which is considered more dangerous as it causes sunburn. Most importantly, both UVA and UVB rays are thought to cause skin cancer. Any lengthy exposure to sunlight, regardless of season, can put one at these risks. Accordingly, dermatologists suggest everyone to use sunscreen daily.

Types of Sunscreens Sunscreens contain filters that reflect, absorb, or scatter UV rays, thereby preventing skin penetration. They can be divided into two main types depending on the filter used, which are organic and inorganic filters. Organic filters absorb UV rays and convert them to safer radiation, while inorganic filters reflect and scatter UV rays away from our skin. The chemical composition of organic filters is oxybenzone, avobenzone, octisalate, and aminobenzoic acid, while that of inorganic filters are zinc oxide and titanium dioxide. It has long been established that inorganic filters are safer, as some organic filters are absorbed into the skin and through the bloodstream. This does not leave organic filters unsafe. Nonetheless, there are rising concerns on the potential effects of oxybenzone, the most commonly used organic filter.

Concern 1: Harmful ingredients ?

Oxybenzone has been at the center of attention due to tenuous claims of it being a hormone disruptor. Hormone disruptors are substances that may interfere with the hormonal system, leading to cancers, birth defects, and other developmental illnesses. There was a study revealing its danger on rats. Young rats that consumed oxybenzone developed abnormal uterus and mammary glands. However, another study proved that it would take around 277 years of sunscreen use to achieve the equivalent consumption of the rats in the study. Hence, there has been no convincing evidence proving its danger to humans. Furthermore, oxybenzone is already commonly used in products including nail polish, hairspray, and plastic. Therefore, the oxybenzone in sunscreen should not be too much of a concern.

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Concern 2: Blocking Vitamin D ?

Aside from concerns on the safety of substances, people are questioning whether sunscreen usage blocks vitamin D absorption. It is well-known that sunlight helps our bodies convert cholesterol to vitamin D. Vitamin D helps regulate calcium and phosphate, allowing us to maintain healthy bones, teeth, and muscles. However, despite the importance, vitamin D deficiency is one of the most prevalent health issues worldwide. Studies showed that about 42% of Americans and about 64% of South Koreans are vitamin D deficient. Even if sunscreen blocks vitamin D absorption, considering the lifestyle of people these days, is this sunscreen to blame?

Sunscreen works by blocking UVB light, theoretically meaning that sunscreen usage lowers vitamin D levels.

But, in reality, many people put on sunscreen irregularly and use amounts that may not be enough to block all UVB rays. Also, a study proved that those who used sunscreen and placebo cream had similar vitamin D levels, proving a low correlation between sunscreen usage and vitamin D deficiency. Furthermore, vitamin D levels vary depending on air quality, weight, age, diet, and lifestyle. Thus, vitamin D deficiency should not be a concern when applying sunscreen.

Benefits of Sunscreen With several concerns resolved, you may understand that sunscreen is not our foe. But could we call it our friend? The answer is yes. Dermatologists recommend people to wear sunscreen throughout the year for the following reasons: 1. Shield harmful UV rays 2. Prevent premature skin aging 3. Prevent sunburns 4. Reduce skin cancer risks If this does not alert you, look at the picture below. This man worked as a truck driver for 28 years, exposing only the left side of his face to the sun. Do you see the difference? The left side of his face, compared to the right side, is more saggy and has more wrinkles. Now, I bet you’ll want to start applying sunscreen regularly from today.

Using Sunscreen Correctly Like everything, using it ‘correctly’ is important. It is recommended to use sunscreen with a sun protection factor (SPF) of 30 or above when going outdoors. SPF 30 is enough as it protects approximately 97% of UVB rays.

Experts recommend using the “teaspoon and shot glass rule”: 1 teaspoon of sunscreen for the face and neck, and 1 full shot glass for the rest of the body parts exposed to the sun. Keep in mind to apply sunscreen at least 15 minutes before going out as it takes time to absorb. In addition, it is also important not to rely on cosmetics with SPF because in most cases, they are not enough to protect your skin.

Getting back to the title, now we can conclude that sunscreen is a friend. Don’t be too bothered about the concerns regarding sunscreen, as there are more benefits than losses. Just remember, never skip sunscreen! B

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COLUMN

Supplement Suggestion for Homebodies How To Take Your Supplements JungWon Kim

D

wjddnjs521@naver.com

ue to the COVID-19 pandemic, people are spending more time at home than ever because of physical distancing. Our immune system consists of a complex collection of cells, processes, and chemicals that constantly defend our bodies against invading pathogens, such as viruses, toxins, and bacteria. Although we all know that keeping our immune system healthy year-round is key to prevent infection and disease, it is especially hard nowadays to make healthy lifestyle choices like consuming nutritious foods, getting enough sleep and exercising regularly. Most people lack exercise, daylight, and nutritious meal. Immune disorders have increasingly become a problem for younger people since their lifestyle has changed a lot since the COVID-19 pandemic. In fact, the incidence of hepatitis A and shingles for people in their 20s increased during 2020. To solve this problem by improving their immune system, many people have choosen to take various nutrition supplements. This is actually a good solution to compensate for insufficient nutrients and activities. However, a combination of various nutritional supplements may lead to synergies, but also side effects. In order not to be exposed to unexpected health problems, it is important to choose a nutritional supplement combination that suits one’s situation.

Multivitamin Most people consider multivitamins for nutrient supplement since various nutrients can be taken with just one pill.

A multivitamin is a good choice when it is difficult to eat a balanced diet which is closely related to energy resource and immune system. However, multivitamins vary depending on how they are manufactured. Thus, it is necessary to know the composition of each product to think whether other nutritional supplements should or should not be added in consideration of the ingredients. Especially for multivitamins, users need to deeply consider about the interactions that may take place when additional nutritional supplements are taken since one capsule contains 10 to 40 different kinds of nutritional ingredients.

GOOD Most people are deficient in calcium and magnesium, which play important roles in the immune system.

However, multivitamins usually do not contain them.

Since calcium and magnesium have larger molecular volumes than most components in the multivitamins, it is hard to put calcium and magnesium in the multivitamin capsule. Thus, calcium and magnesium should be taken with multivitamins.

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BAD Multivitamins and iron should not be taken together.

Though iron is a helpful nutrient, it is not fully absorbed when taken with multivitamins since minerals in them prevent its absorption. Multivitamins and vitamin A should also not be taken together. Vitamin A is often taken with multivitamin since it is considered the same vitamin family. However, vitamin A, a fat-soluble vitamin, is stored in the body unlike multivitamins which are made up of water-soluble vitamins. One should be careful not to take multivitamins and vitamin A together at the same amount.

COLUMN

Omega-3 Omega-3 is a type of fatty acid which is an essential nutrient especially at times like this when people spend most of their time indoors. This is because omega-3 improves blood flow through anti-inflammatory actions in the body, helping prevent many cardiovascular diseases. Omega-3 also improves the fatigue and dryness of the eyes due to the prolonged use of smartphones and television as people spend more time at home. Since omega-3s are fatty acids, people should take extra care of choosing the right combinations of nutritional supplements.

GOOD Coenzyme Q10 is an electron carrier in the mitochondrial respiratory chain that can produce energy in the form of ATP. It is also known for its antioxidant properties.

Therefore, taking omega-3 with coenzyme Q10 together can help strengthen the cardiovascular system. Also, studies show that absorption increases when coenzyme Q10, a fat-soluble substance, is taken with omega-3 fatty acids. For similar reasons, lutein and omega-3 can be a good combination of nutritional supplements for eye health.

Vitamin E and omega-3 are also a good combination of omega 3 due to the auxiliary function of vitamin E. Omega-3 is a type of unsaturated fatty acid which is easily oxidized. However, when omega-3 is taken with vitamin E, omega-3’s oxidation is prevented and effect is well-maintained. For this reason, most commercially sold omega-3s contain vitamin E compounds.

BAD As people spend less time doing outdoor activities, more people are having difficulty in maintaining their body weight, people have gained more interest in dietary supplements such as chitosan that helps reduce body fat. However, taking chitosan with omega-3 is not recommended. Chitosan reduces body fat by inhibiting absorption in intestinal fat and promoting excretion. As a result, when chitosan and omega-3 are taken together, the fat-soluble omega-3s are also excreted from the intestines, significantly reducing its actions.

Although various supplements may boost the immune system, they cannot replace a healthy lifestyle. Maintaining a balanced diet, getting enough sleep, engaging in regular physical activity, and not smoking are the more important ways to keep your immune system healthy and reduce the risk of infection and disease. B

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COLUMN

Ketogenic Diet Seo Woo Park

pinkwoo97@yonsei.ac.kr

T

he world is in the midst of a keto craze. In 2019, “keto diet” was one of the most-Googled diets in the United States. It also deluged social media with recipes and stories of its weight loss efficacy. This trendy diet focuses on high fat and low carbohydrates food. Did you know that this diet was actually created for controlling seizures in children with epilepsy? Let’s look in-depth into this fascinating diet through this column!

Brief History In the 19th century, ketogenic diet was used to help control diabetes. The value of this diet was brought to light in 1921. The diet was introduced as an effective treatment for epilepsy in children whose medication was ineffective. Since then, this diet became the last resort treatment for many children, adolescents, and adults with epilepsy medication resistance. Despite the remarkable development of anti-epileptic drugs, they are unfortunately not fully effective for about one-third of epilepsy patients. Ketogenic diet thus remains as a vital anti-epileptic nonpharmacological therapy worldwide. Furthermore, the diet is studied as a therapy for polycystic ovary syndrome, Alzheimer’s disease and cancer nowadays. There are also recent studies showing a close relationship between epilepsy and the intestinal microbiome.

What is Keto Diet / Ketogenic Diet?

Ketogenic diet starts with replacing carbohydrates by fats in our daily meals. For example, “keto-friendly” foods include eggs, butter, unprocessed cheese, avocados, meat, low-carb veggies, nuts and seeds. To be more specific, keto diet involves a very high-fat and low-carbohydrate diet, reducing carbohydrate to ≤10% of consumed energy. By eating keto-friendly foods, we can achieve a macronutrient ratio of 4:1, where 4 is fat and 1 is protein and carbohydrates. Restriction of carbohydrates encourages a systemic shift from glucose metabolism to fatty acids(Fas) metabolism yielding ketone bodies(KBs). Ketone bodies include acetoacetate and β-hydroxybutyrate. The key idea is that brain uses glucose as a main source of energy. Since ketogenic diet lacks carbohydrates, the dominant fuel source glucose is replaced with ketone bodies in the brain.

Epilepsy and Seizure It is easy to confuse epilepsy with seizures. So, let’s look into each definition before we go over with the relationship between epilepsy and the keto diet. Epilepsy is a chronic disorder that causes unprovoked, recurrent seizures. More specifically, it is defined as the occurrence of two or more unprovoked seizures. Idiopathic epilepsy is a common type of epilepsy in which the cause of the disease is not identified. Seizures, on the other hand, are short episodes of involuntary movement. They can be classified into two groups: partial seizures and generalized seizures.

For example, when a tonic-clonic seizure starts, it causes stiffened muscles, jerky arm and leg movements.

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COLUMN

For complete seizure freedom, elimination of symptoms, minimized side effects, and guarantee of quality of life, pharmacotherapy or nonpharmacologic therapy is provided as a treatment. While pharmacotherapy involves the use of anti-epileptic drugs, nonpharmacologic therapy includes : vagus nerve stimulation, temporal lobectomy, and ketogenic diet. Ketogenic diet can be considered for the one-third of the patients who are resistant to drugs or surgical treatment.

Anti-seizure Mechanism Then what is the anti-seizure mechanism of the ketogenic diet? Sadly, the anticonvulsant mechanisms are not completely understood. However, it is believed that the increase in KBs encourages biosynthesis of mitochondria, oxidative phosphorylation, and rise in GABA level. These lead to the stabilization of synapse function at the central nervous system. As mentioned above, changes in brain metabolism occur during ketogenic diet since brain is originally supplied with energy mainly by glucose. As a result, seizure threshold increases and seizure frequency decreases. To summarize, a significant decline in seizure frequency by the ketogenic diet enhances patient’s quality of life.

Adverse Effects of the Ketogenic Diet Does keto diet only have good therapeutic effects? The answer is No. The followings are possible adverse reactions associated with the administration of a ketogenic diet. To prevent adverse effects, supplement of vitamins and calcium are needed. Also, drinking sufficient water will prevent dehydration and renal stone.

- Severe dehydration *Long-term AEs - Acidosis - growth retardation in children - Lethargy, lack of energy - hypercholesterolemia - Somnolence - renal stone - Severe infections - increased risk in bone fracture - Mood swings - Vomiting, nausea

Other Health Benefits of Ketogenic Diet Even though the diet was originated as a treatment for epilepsy, recent studies have shown that it can have benefits for a variety of health conditions: - Heart disease : Ketogenic diet can improve body fat, HDL cholesterol level, glucose level and blood pressure.

- Cancer : Ketogenic diet probably creates an unfavorable metabolic environment for cancer cells and thus can be regarded as a promising adjuvant. However, more studies and clinical trials are needed to further elucidate the mechanisms.

- Alzheimer’s disease. : The presence of ketone bodies has a neuroprotective impact on brain cells. They enhance mitochondrial function and reduce the expression of inflammatory and apoptotic mediators. Thus, the diet has gained interest as a potential therapy.

- Polycystic ovary syndrome. : Ketogenic diet can help improve insulin resistance and promote weight loss, both of which may be beneficial for polycystic ovary syndrome. B

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COLUMN

Solidarity in Health:

what we need right now

T

Jiyoun Son

son.jiyoun@yonsei.ac.kr

ime has passed since the first outbreak of COVID-19 and it is evident that this pandemic is not an urgent task for only governments or major organizations. Everyone is struggling at the frontline of this pandemic. Scientists broke down their walls and began to join hands with other colleagues. They stopped their research and formed a global collaboration. Never before have so many multinational experts focused on one purpose simultaneously and urgently.

The virus pushed the scientific community in an unprecedented way. This reflects the fact that the danger zone is not someone else’s story. It is no longer a problem concerning a few villages on the other side of the world. Our own community is in danger, making everyone responsible.

“Community” and “Community Health”

But let’s put aside all the difficult scientific research talk for a moment. Here’s a more fundamental question. What is the nature of the term “community” nowadays? Is it synonymous with the word “neighborhood”? Almost everyone lives in a neighborhood, but not all of them are a part of the community. What determines people’s community ultimately depends on how they perceive their relationship with their communities. To become members of a community is to play a role in local affairs or socially interact with others. Even if a community has low population density or lacks basic facilities, people will act as community members if they perceive that they are part of it. These perceptions will lead to behaviors that are beneficial to themselves and further on, their community.

Then what is the term “community health”? Does it affect us individuals? Community health is a medical specialty that focuses on the overall well-being of the people in a specific community. This includes initiatives aimed at maintaining and improving the health of community members, preparing for natural disasters, preventing the spread of infectious diseases, and so on. As good community health leads to more people being healthy, community health and personal health are of course inseparable.

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COLUMN Unfortunately, many people are unaware of the role of community healthcare in their everyday lives. Lack of community healthcare can lead to complex problems that are difficult to solve individually, especially during times like this. Blocking the spread of infectious diseases is a priority for community health programs these days. If community healthcare does nothing about this, we would be fighting an outbreak that puts vulnerable populations at a higher risk. The elderly, low-income and self-employed, and mentally and physically disabled people would not have any shield to protect themselves. Thus, enhancing community health is a systematic undertaking that public workers, local governments, and citizens have to deal with together. This type of community engagement is essential to combat COVID-19. Global health guidelines have already emphasized the importance of community engagement. It is a proven fact that we work better along, with our community members by our side. So how can we specifically co-produce community healthcare in the context of an emergency like COVID-19?

What should we do?

First, governments should immediately set up and fund community task force. They should actively engage in providing the right information to the public and ensure the community that their voice is being heard. Preventing the spread of the virus through epidemiological investigations is essential. Additionally, it would be their duty to provide access to locations for self-quarantine and explore options to protect the weak in this situation. Protecting renters from evictions, expanding childcare services, and providing safe public transportation services would also be needed. Overall, they should manage the demand for community healthcare and help community members manage their risks.

Next, policymakers should help people understand what social tracing is. People may feel that their privacies are invaded if social tracing is not explained beforehand. For example, public health workers need to continuously inform and help community members understand why they need to track down people’s contact. These actions will in turn help increase compliance with other social regulations. Furthermore, policy enforcement based on understanding will create a social atmosphere that encourages sharing creative ideas and solutions. There are many cases where community members have come up with more ingenious, practical solutions. Thus, policymakers should collaborate with scientific researchers, community organizations, and the public to share information and ultimately prevent COVID-19.

Furthermore, private organizations can promote preventive measures such as social distancing, using masks, frequent handwashing, and staying home. Whilst achieving these goals, it is recommended to work with trusted local media such as hiring people from the community to share COVID-19 prevention messages. Also, being open to community volunteers while protecting them would help. More importantly, finding workers who are in need of help and leading them to appropriate resources and services, including COVID-19 testing and vaccines, is crucial.

Last but not least, the entire community, people like us, should be prepared. An informed, engaged, and empowered community is the basis for the COVID-19 vaccines, treatments and tests. As the community actively participates in the cycle of planning, providing and applying new biomedical tools, the demand and usage for these tools will increase.

Empowering the community is not an abstract idea. There are specific and measurable steps, such as risk communication and community engagement (RCCE), which are effective on the assessment of new vaccines or WHO COVID-19 guidelines. By taking these steps together, we can promote trust, which is the key element of every community.

It has been more than a year since the first case of COVID-19 occurred, and it is still disrupting our health, economy, and every aspect of our society. At times like this, we need to cooperate and value solidarity. Solidarity makes us stronger directs us towards a better future. Solidarity is not just a sense of compassion or distress about others. It is a firm belief to commit ourselves for the common good because we are responsible for our community. If everyone is not protected, no one is safe. B 2021 VOL.19

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NATIONAL ISSUES

e-mart, on the Border of Noise-Marketing and Tyranny Sang Soo Na

“N

sangsoo66@yonsei.ac.kr

o Brand. It’s not about the brand, it’s about the customer.” This is the slogan put by e-mart’s private brand ‘No Brand.’ It dismisses the branding process as an extravagance and seeks to ease the cost burden. Extending its business philosophy, e-mart applied for a new private brand trademark application on February 17th regarding its health functional food product line. What caused controversy was its name, ‘No Pharmacy.’

To begin with, we must identify what health functional food is. In Chapter 1, Article 3 of the Health Functional Food Act, health functional food is defined as “food prepared with raw materials or ingredients that are advantageous for the human body.” It can be sold by drugstore founders (Article 20, Pharmaceutical Affairs Act) and registered food dealers (Article 15, Special Act on Imported Food Safety Management). Since anyone can legally merchandise health functional food, e-mart has no trouble jumping into the health functional food market.

Where it all started Then, what was the problem? There were two main issues. The first was the brand name itself. The word “pharmacy” is, in fact, protected by the law.

That is why pharmacies cannot be established by

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those other than pharmacists, and the title ‘pharmacy’ is not to be arbitrarily authorized (Section 1, Article 20, Pharmaceutical Affairs Act).

‘No Pharmacy,’ however, not only goes against the Act but also diminishes the function of pharmacies and pharmacists.

The second issue was the expertise of the items being merchandised. Of the items that ‘No Pharmacy’ registered for trademark application, a majority of them were registered for “medical care use” or “veterinary use,” incurring anxiety of those who question medical professionalism of ‘No Pharmacy.’ Mono Labs, a startup company that supplies health functional food to e-mart, took a step back and claimed that there are no specific plans consulted with e-mart. More importantly, e-mart is not yet ready for the health and medical market, as it needs to institute extended and complex judicial proceedings with healthcare professionals.

NATIONAL ISSUES

K-Pharmaceutical Association’s Position

e-mart’s Position

As much as it is an issue, the Korean Pharmaceutical Association revolted against e-mart’s decision to apply for such trademark. Beginning with Gyeonggi-do Pharmaceutical Association’s first state of opposition on February 20th, regional Pharmaceutical Associations in other cities added strength to the voice and condemned where e-mart was headed. Young-dal Park, the chairman of Gyeonggi-do Pharmaceutical Association, posted a national petition on February 24th with the topic “Dear Mr. President, please help stop the tyranny of chaebol companies” in an effort to draw public attention.

Unflinchingly, Mr. Park marched up to the front gate of the Blue House for a one-man protest. He claimed that “I chose the Blue House over e-mart’s head office in a favor of the government to arbitrate the current situation.” He continued that “this is not a remonstrance, but rather an earnest request to persuade the huge company.”

Initially, e-mart seemed adamant. It rebutted that “there is no derogatory intention in the name ‘No Pharmacy,’” and that “it was meant to tear down the hurdle of accessing health functional food.” It continued “we wanted to give an impression that health functional food is not a medicine, but a habit.” It ended on the note that “the trademark application was done in terms to defend future trademark candidates.”

Conclusion

Despite the explanation, the backlash did not easily subside. The pharmaceutical society registered ‘No e-mart’ trademark application and urged the government to take action. On February 24th, a meeting was arranged between the Korean Pharmaceutical Association and e-mart. They clarified each other’s position on the current issue. After a few days, e-mart indicated its stance on the crisis. It apologized to the Pharmaceutical Association that “regardless of what the intention was, we ask for forgiveness in arousing negative impression on pharmacists and pharmacies.” It added that “we overlooked the meanings and roles that pharmacies and medicines have as public assets in the society.” e-mart decided to voluntarily withdraw the trademark application, hoping for mutual growth with the pharmaceutical society.

After all, the situation was no different from the time before the controversy. Nothing had changed, but the pharmaceutical society was offended and e-mart had to undergo a meaningless application and withdrawal process.

Borrowing words from an anonymous pharmacist, e-mart “should not have stepped off the wrong foot to begin with,” when there is so much to lose but nothing to gain. B

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INTERNATIONAL ISSUES

Can Climate Change Trigger New Diseases Outbreak?

Jihye Seo sjihye@yonsei.ac.kr

T

he temperature of the globe is rapidly rising every year due to human activities. Consequently, the greenhouse gas is heating the temperature of ocean, causing drastic climate changes like sweltering heat, prolonged monsoon, harsh desertification, or extremely cold weather. In fact, the average temperature of the planet has increased by 0.8º Celsius compared to the end of the 19th century. At the pace of current CO2 emissions, scientists expect an increase of between 1.5°and 5.3° C in average temperature by 2100. As a result, thousands of habitats for wild lives will be diminished and ecosystems of those areas will change. Humans are also in danger of the loss of territories and food shortage. Surprisingly, global warming can also bring harmful diseases. Scientists are now warning that new health hazards may hit the globe if climate change continues. But how is it possible? Here are some examples of how it works.

Heat wave: Waking up dormant pathogens The annual average temperature of Siberia and the Arctic regions are continually rising. You may have heard of the news that well-preserved fossils of mammoths and wolves eroded from the ground soon after some part of the permafrost thawed. However, the ancient creatures are not the only things that surprise scientists. Researchers are now warning that “the dormant bacteria and virus” can be unleashed from the soil or ice if global warming continues.

In July 2016, more than 2,000 reindeer and a 12-year-old boy died suddenly in Siberia. Surprisingly, there was a reindeer carcass 75 years ago in that region. Researchers claimed that the spore of Anthrax bacteria remained locked in permafrost until remarkably warm summer came. The infectious dormant spores have kept themselves safe in soil for centuries and revived as soon as they got the chance. Researchers have warned for years that the burial grounds of anthrax-stricken cattle and reindeer in Siberia can be a random time bomb that brings new epidemic. Unfortunately, no one can guarantee how deadly it could be. In the worst scenario, modern medicines won’t work on ancient pathogens since their genetic characteristics might be different from those of contemporary ones. Then how could the virus move so far? The researchers claimed it is related to extreme El Niño in 2015-2016 which formed a favorable condition for ZIKV spreading. Recent studies reported that extreme El Niño events will double in the future and the increase of its frequency will continue in response to greenhouse warming. In other words, people will get more chances to get ZIKV diseases.

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INTERNATIONAL ISSUES

Rainfall: Rising opportunity to get waterborne diseases Flood is the most common and deadly natural disaster worldwide, which is caused by high rainfall, tidal extremes, and structural failure. Floods may cause the overflow of wastewater treatment plants or failure of septic systems lead to contamination of nearby surface waters or wells. According to a systematic review, there is a sig­nificant association between heavy rainfall and diarrheal diseases. For example, the positive relationship between heavy rainfall during monsoon months and diarrheal outbreak were recognized in the Philippines. Some research showed that the floods make an adequate environment for particular pathogens, such as Escherichia coli and Vibrio cholera.

A number of immediate outbreaks after rainfall due to contaminated water supplies were reported worldwide. The water flow accelerates the spread of bacterium, then it can infect more people. On the other hand, a warmer atmosphere holds and subsequently pours more water leading to more frequent floods. Those changes may enhance the primary and secondary transmission of cholera in developing nations, particularly among populations settled in low-lying coastal areas of tropical regions. In 2014, a multinational team of researchers found a 700-year-old virus in the feces of reindeer buried in a permafrost in northern Canada. They recognized the old virus is capable to infect modern plants. This may be a harbinger of an epidemic that mankind has never experienced.

El Niño: Change in distribution of disease-carriers> The diseases which were restricted to certain areas may spread due to climate change in future. The disease carriers, like mosquitoes or mites, can be able to migrate to another area where they couldn’t live before. Zika virus (ZIKV), an insect-borne virus mainly transmitted by Egyptian mosquitoes, is one good example. ZIKV infection results in no or only mild symptoms, but it can cause microcephaly of the fetus when it moves from a pregnant woman to her baby. ZIKV was originally prevalent in some African and Asian countries near the equator in the 1950s. In 2007, however, the virus spread across the Pacific Ocean and the first ZIKV outbreak was observed on the Yap Islands in Micronesia. At first, the scientists were shocked since it meant the virus is no more limited to Africa and Asia. Soon the spread continued to Oceanian countries like Australia, New Zealand, and French Polynesia between 2012 and 2014. Finally, there was a ZIKV epidemic in 2015 and 2016 in Latin America. It was estimated that 1.5 million people were infected by the virus and 3,500 cases of microcephaly were confirmed.

To conclude..

The relationship between human health and climate change is not a new concept anymore. Then is it too late to slow down global warming and prevent new disease outbreaks? Even with the alleviation procedures for 20-30 years, global warming issues have not been resolved. And it is generally accepted that the results of global warming on infectious diseases have not been apparent at this point yet. These consequences, however, will arise in one form or another if climate change continues to progress in the future. According to a WHO assessment, global climate change is expected to cause approximately 250,000 additional deaths per year between 2030 and 2050. Hence, more policies and individual choices that can potentially reduce greenhouse gas emissions are needed. We need to endorse limiting carbon emissions, using renewable energy sources, building sustainable infrastructures, and forest managements to save ourselves from climate hazards. Moreover, preparing appropriate adaptation measures to the effect of global warming on human health can be practical action we can take. It’s not a choice, it’s a must. B

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INTERNATIONAL ISSUES

MONOCLONAL ANTIBODY TREATMENTS FOR COVID-19 Gayoung Lee

dlrkdud724@naver.com

The First Monoclonal Antibody Treatment for COVID-19 That Has Been Granted Emergency Use Authorization by the FDA Many Pharmaceutical companies have tried to develop monoclonal antibody treatments for COVID-19. Finally, on November 9, 2020, the U.S. Food and Drug Administration (FDA) has issued an Emergency Use Authorization (EUA) to permit the emergency use of bamlanivimab (LY-CoV555; Lilly) for treatment of recently diagnosed mild to moderate COVID-19 in adults and pediatric patients of 12 years or older weighing at least 40kg. Bamlanivimab has been only permitted for patients who are at high risk of progressing to severe disease or hospitalization. It should not be used for hospitalized COVID-19 patients who require high oxygen flow or mechanical ventilation; because ‘monoclonal antibodies’ may worse clinical outcomes.

The mechanism of Bamlanivimab is as follows. It binds to the receptor-binding domain of the spike protein of SARS-CoV-2, blocking the spike protein’s attament to the human ACE2 receptor. It can then neutralize the coronavirus and completely cure COVID-19.

In phase 2 of the clinical trial, patients had been divided into four groups: placebo, 700mg, 2000mg, 2800mg of Bamlanivimab. Patients in the placebo group are given drugs such as Remdesivir which was previously used in hospitals to treat COVID-19. Before the trial, researchers must decide the primary endpoint. The primary endpoint is the main measurement that assesses if a given treatment worked, answering the most important question. There also can be a secondary endpoint, which is an additional endpoint monitored to help interpret the results of the primary endpoint. The primary endpoint of this trial is the decrease from baseline in SARS-CoV-2 viral load on day 11. The baseline indicates an initial measurement of a condition that is taken at an early time point. It is used for comparison over time to look for changes.

One of three doses of Bamlanivimab appeared to accelerate the natural decline in viral load over time. The patients who had received the 2800mg dose had a greater decrease by 0.53(unit) in viral load from the baseline than the placebo group. This means that their viral load is lower by a factor of 3.4 compared with the placebo group’s viral load. There are smaller differences in the decrease of viral load between patients in the placebo group and patients who received 700mg or 2000mg doses.

The secondary endpoint of hospitalization or emergency department visit for COVID-19 had appeared by day 29. 1.6% of patients in the LY-CoV555 group and 6.3% of patients in the placebo group had visited an emergency department or had been hospitalized due to COVID-19 by day 29. This result implies that LY-CoV555 reduces hospitalization or visits of mild/ moderate patients by almost 75%.

Regeneron’s Casirivimab and Imdevimab Antibody Cocktail for COVID-19 On November 21, 2020, REGN-COV2, the antibody cocktail of casirivimab and imdevimab has received EUA from the FDA for the treatment of mild to moderate COVID-19 in adults and pediatric patients. REGN-COV2 is

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INTERNATIONAL ISSUES

authorized for patients of the same condition as LY CoV555.

The clinical evidence from Regeneron’s outpatient trial suggests that monoclonal antibodies yield the greatest benefit when they are quickly given to patients after diagnosis. This is because it is most effective when the patients have a high viral load and have not yet mounted their own immune response. REGN-COV2 is not authorized for use in patients who are hospitalized, require oxygen therapy due to COVID-19, or use chronic oxygen therapy.

Cocktail treatment using Bamlanivimab and Etesevimab On March 10, 2021, Eli Lilly and Company had announced new data from the randomized, double-blind, placebocontrolled Phase 3 study. Bamlanivimab (LY-CoV555) 700mg and Etesevimab (LY-CoV016) 1400mg together had significantly reduced COVID-19 related hospitalizations and deaths in high-risk patients recently diagnosed with COVID-19. These results provide additional efficacy and safety data that support the use of the dose granted by EUA before. This cocktail treatment is authorized for patients with the same condition as LY CoV555 and REGN-COV2, but it also includes treatment for those who are 65 years old and above or have certain chronic medical conditions.

Bamlanivimab and Etesevimab are both monoclonal antibodies that are specifically directed against the spike protein of SARS-CoV2. They bind to different but overlapping sites on the spike protein of the virus.

Celltrion received conditional approval for CT-P59.

On February 5, 2021, the Ministry of Food and Drug Safety (MFDS) in Korea granted conditional approval for Celltrion’s CT-P59 to market its COVID-19 treatment, CT-P59(regdanvimab), to patients with mild to moderate symptoms. The ministry has decided to authorize the drug under the condition of submitting the third clinical trial result. The conditional approval for CT-P59 is the first COVID-19 treatment developed in Korea, and the third in the world.

During the trial, CT-P59 had significantly reduced the risk of COVID-19 related hospitalization and oxygenation up to Day 28. The rate of progression to severe COVID-19 up to Day 28 was reduced by 54% in total patients with mild-to-moderate symptoms, and 68% in 50 years or older moderate patients with pneumonia compared to patients in the placebo group. CT-P59 also shortened the clinical recovery time of total patients, moderate patients with pneumonia, and moderate patients aged 50 or older, by 3.4 days, 5.1 days, and 6.4 days earlier compared to the placeb group, respectively. Again, patients in the placebo group were given previously used drugs that were used in hospitals to treat COVID-19.

After the conditional approval in Korea, Celltrion tried to receive authorization from EMA and FDA. Finally, on March 26, 2021, the European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) has issued a positive scientific opinion for CT-P59. According to the CHMP recommendation, CT-P59 can be used to treat patients with high risk of progressing to severe COVID-19, based on a reasonable possibility that the medicine could offer clinical benefit and a reduced chance of causing harm.

Many other pharmaceutical companies are also trying to develop treatments and vaccines for COVID-19 despite many difficulties. Even though the COVID-19 pandemic is a difficult time, it gave us lessons on over-coming a pandemic and promoted the development of pharmaceuticals. Everyone is waiting for the day to win the war against coronavirus. I hope the development of the COVID-19 medications are bringing us one step closer to the end of this pandemic. B

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LIFE ISSUES

Allurements of Carbohydrates : Importance of Nutrition Facts Label Donghyeon Kim kdhbbr@naver.com

Result of today’s over-consumption of carbohydrates

C

arbohydrates are one of the most representative fuel that make our bodies move. They are important because they can be used as an immediate energy source. Nevertheless how important they are, eating more than you need is harmful. Adult diseases such as diabetes, high blood pressure, hyperlipidemia, obesity, and many other illnesses are closely related to the intake of excessive carbohydrates. In the United States, average carbohydrate requirement is 100 grams for all ages. In South Korea, about 55-65% of total energy intake is recommended. This means that if a person’s daily calorie intake is 2,000 kcal and if 60% of it is carbohydrate, carbohydrate consumption will be 300 grams. However, South Korea’s average carbohydrate intake is 314.5 grams according to the 2012 National Health and Nutrition Survey.

This result shows that South Koreans are consuming more than the recommended intake amount despite they are less conservative and much wider tolerant than the those of United States.

The body releases insulin to lower blood sugar level increased due to excessive carbohydrate intake. This allows glucose in the blood to be stored as glycogen in the liver and muscles. If the amount of glucose and glycogen exceeds the required amount, surplus glucose is converted to fat and stored in many parts of the body. This excessive accumulation of fat in the body can cause adult diseases. Then what should we do to choose the right food? We should analyze nutrition labels.

Types of carbohydrates and absorption mechanisms

Understanding basic types of carbohydrates, metabolism, and absorption is needed to analyze the nutrition fact label.

Carbohydrates consist largely of glycoside and dietary fiber. Glycosides consist of monosaccharides, disaccharides, and polysaccharides. We call monosaccharides and disaccharides as saccharides. Thus, carbohydrates are composed of saccharides, polysaccharides, and dietary fiber. Monosaccharides exist as molecules of sugar, which are glucose, fructose, and galactose. Disaccharides are combinations of two monosaccharides, which are maltose, sugar, and lactose.

Polysaccharides and dietary fiber have similarities and differences. They are both combinations of monosaccharides. The difference is that polysaccharides can be broken down and absorbed as monosaccharides to be used as an energy source.

However, dietary fibers do not have any enzyme that can break them down to monosaccharides; therefore cannot be used as an energy source.

Next, you should know about the absorption of carbohydrates. The absorption of sugar is mainly done in the small intestine. It is absorbed only in the form of monosaccharides. Since monosaccharides, disaccharides, and polysaccharides can all be absorbed to monosaccharides, this in turn raises blood sugar levels. However, dietary fibers, which cannot be broken down into monosaccharides, cannot be absorbed in the small intestine, and therefore do not raise blood sugar levels.

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In addition, it takes time for disaccharides and polysaccharides to be broken down and absorbed by enzymes in the form of monosaccharides in the digestive tract. As a result, the smaller the number of sugars combined, the faster sugar will be broken down, and thus increase the absorption rate. Finally, importantly, polysaccharides, unlike dietary fibers, are reflected in 100% blood sugar, although their absorption rate is slower than that of monosaccharides and disaccharides.

How do we analyze the nutritional table?

So what carbohydrates should you take and how can you tell that those carbohydrates are appropriate for you? As mentioned in part 1, most people are consuming more carbohydrates than recommended. This can cause inflammation and lead to various adult diseases, which begins from an excessive increase in blood sugar.

In part 2, it was mentioned that monosaccharides and disaccharides raise blood sugar quickly. As blood sugar rises, insulin may also be secreted in excess, causing fat accumulation and inflammation. To reduce this phenomenon, eating dietary fiber-rich food that do not raise blood sugar can help. In contrast, polysaccharides increase blood sugar slowly, providing the energy needed immediately, while not increasing insulin levels. Therefore, if you are not highly active, it would be beneficial to increase polysaccharides consumption rather than monosaccharides and disaccharides.

How can people apply the advices given above to their daily lives? In general, nutrition labels are on food packages.

Snacks, packaged foods, and instant foods that are sold at the supermarkets all have nutrition fact labels on the cover.

Nutrition facts for fish, fruits, and vegetables, that do not have nutrition fact labels can be found online. Rather than only thinking these nutritional fact labels are difficult, you should actively check them, if you think they can explain what you eat.

The nutrition fact label of the food we buy shows that saccharides including sugar and dietary fibers are marked within the category ‘total carbohydrate’. Thus, even though the total amount of carbohydrates is important, its composition should be prioritized. For example, food A has 50g of total carbohydrates, composed of 40g of monosaccharides and 10g of disaccharides. Food B has 100g of total carbohydrates, composed of 40g of dietary fiber 40g of polysaccharides and 20g of monosaccharides. In this case, food A has lower total carbohydrate. However, if you look closely at the composition, food B is rich in dietary fiber which is not used as an energy source. It contains 20 grams of monosaccharides that raise blood sugar rapidly, while food A contains less total carbohydrates than that of B. Therefore, depending on the situation, it can be more appropriate to choose food B than food A. In conclusion, you should consider the amount of dietary fibers, not the amount of total carbohydrates. Also, since polysaccharides are more slowly absorbed than those of other two types of sugars, they inhibit rapid increase of insulin, while providing the energy required.

However, the choice above focuses on the general case of people who have low activity. If you are very active and enjoy strenuous exercise, it will be helpful to consume monosaccharides and disaccharides rather than polysaccharides and dietary fibers for fast absorption of sugar and rapid usage of them as energy. Therefore, it is most important to analyze the nutritional content table according to your lifestyle and to eat foods that will help you. B

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LIFE ISSUES

Do you own your mind?

Chae Hyun Lee

chaehyun.lee96@gmail.com

W

hat was the first impression of your best friend? Did you feel like you could be life-long friends at first sight?

Some may say yes, and some may say no. However, more often than not, people decide if they like a person in just a couple of seconds without realizing it. This part of the mind, the subconsciousness, takes up a significantly large fraction of your mind. So, who’s actually controlling your mind – you or your subconsciousness?

Underneath the consciousness Consciousness is the part of our mind within our awareness boundary. This refers not only to our senses, but also our feelings, memories, future goals, and thoughts that we are aware of. On the other hand, the subconscious parts are all the other feelings, thoughts, and emotions that are deep within our minds and beyond our awareness boundary. Sigmund Freud, the founder of psychoanalysis, compared the conscious and subconscious to an iceberg.

The tip of the iceberg that floats above the water is the conscious mind, while the large part of the iceberg hidden underneath the water is the subconscious mind. Furthermore, many psychologists claim that this hidden part of the iceberg takes up a greater part in our life decisions than we think. This may lead to people thinking; “Should we just be devastated about the fact that we cannot do anything about our flow of thoughts?” The hopeful fact is that by recognizing and understanding how the subconscious mind works, we can use this to our advantage.

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Priming our subconsciousness Many experiments have been carried out to show that the subconscious can influence behaviour. John Bargh, a psychologist, initiated an experiment by making a sample group of students take a scramble sentence test, where students had to make a four-word sentence from the five words which are not in grammatical order. For example, if the phrase ‘shoes give replace old the’ is given, the participants would rearrange it into ‘replace the old shoes’. The participants were given several scrambled phrases to rearrange. The students just thought that this was a language test, but what the psychologists were doing was purposely adding words such as ‘old’, ‘lonely’, ‘gray’, and ‘wrinkle’ in the phrases. What they noticed was quite eye-opening; directly after taking the test, the students walked down the corridor a lot slower than they did before they took the test. The subconscious thought of being old caused the students to walk slowly. This technique is referred to as “priming”, whereby the exposure to one stimulus influences how people react to the following stimulus without being aware of the connection.

Our minds are primed in various ways in which we do not realize, and it is important to try to be alert. It is often used as a tactic in marketing to convince the customers to buy the product. For example, a furniture company tested out 2 designs for the website: one with clouds and another with coins on the main page. The one with clouds led to a higher sale of sofas that were promoted for their comfort and softness while the one with coins led to a higher sale of low-priced sofas. Even so, when the customers were interviewed, they did not remember what image was on the main page. The company thus found out that putting clouds on their main page will lead the customers into buying the soft, comfortable sofa regardless of the price. This method is often used in sales marketing. As customers, however, it is necessary that we try to be aware of these subtle hints that the company is flashing, so that we can make choices solely based on our needs.

Countering subconsciousness Learning more and more about how the subconsciousness works and reading examples of how this is purposefully used to prime our minds can be disturbing for some, or even overwhelming for others. So, isn’t there any way we can use this idea to our advantage? It is not impossible to alter the subconsciousness. Social bias is often inevitable due to the prejudiced images portrayed in media. Seeing black men play the bad guys in movies is going to make you relate “bad” with “black people”. Seeing only men act as billionaires is going to make you relate “rich” with “men”. Although there are movements to change these conventions, we as viewers must try to question everything we see, and to read books or watch movies which represent various points of view. This way we can re-fill our subconsciousness with the idea that we want.

To conclude, the instinct is not to be ignored, as it is crucial in many social and personal decisions; the “gut feeling” is there for a reason. However, instinct should not be the basis of all decisions. So, trust your instincts but make sure to keep them in check at the same time. B

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LIFE ISSUES

Burnout Syndrome: a tired society Youngeun Choi

L

karenchoi@naver.com

ast year, Jin, a member of the famous K-pop boy band group BTS, revealed his burnout experience. What is this burnout or, to be specific, BURNOUT SYNDROME? This term was first introduced in 1974 by an American psychologist called Herbert Freudenberger. It was initially used to account for clinic staffs who experienced severe stress and exhaustion due to high work demands.

According to the World Health Organization (WHO), “Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” It is characterized by three conditions in the following: 1) Feelings of energy depletion or exhaustion 2) Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job 3) Reduced professional efficacy

Is Burnout syndrome a type of Depression?

Whether Burnout syndrome is a mental or psychiatric condition is still on a debate. Many papers and studies are focusing on Burnout syndrome and comparing it to depression. There are many symptoms of depression, including the three characteristics of Burnout syndrome. However, depression has other features like low self-esteem, hopelessness, and suicidal tendencies. Also, burnout is a narrower concept than depression as it specifically indicates occupational stress. One who experiences burnout has a high tendency to undergo depression, but not vice versa.

Burnout syndrome in South Korea Burnout syndrome is an issue nowadays in South Korean society. South Korea is known for its busy “pali-pali”(hurryhurry) work culture. This pali-pali culture does not only imply ‘fast’ but also ‘perfect’. Because of endless competition and pressure, people are expected to do things faster and perfectly at the same time. Unlike many Europeans who emphasize more on their personal life and leisure, South Koreans are pushed to work until late at night, leaving less time to focus on their personal life. About 85% of the employees in Korea claimed that they have experienced burnout.

Since the outbreak of the COVID-19 pandemic, our lives have changed entirely. The harsh lives of the employees in South Korea became even harder due to the pandemic. The pandemic situation has been continued for over a year now. People around the globe are still suffering from this ongoing quarantine lifestyle. Along with “Corona blue”, Burnout syndrome became more and more serious among people compared to that before the pandemic. Not only employees who are working in offices or from home, but people who are working in the field fighting against COVID-19 are alsoexperiencing even more drastic psychiatric difficulties. As hundreds of new COVID-19 cases are still coming out daily in South Korea, contact tracers have been overworking for more than 100 additional hours per month. A study showed that over 80% of contact tracers in South Korea are experiencing high levels of burnout with a high average emotional exhaustion score.

Am I also in Burnout condition?

Burnout syndrome is often confused with normal exhaustion. Unlike normal exhaustion which you get recovered if

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you rest well, you will consistently feel severe exhaustion for over 6 months. Therefore, you should not neglect the signs of burnout and be aware of your mental health.

Here is a simple self-test for Burnout syndrome from ‘MindTools’. Anyone can be suffering from burnout. Let’s check whether you are also experiencing it.

< Burnout Self-Test >

Not at All = 1 Rarely = 2 Sometimes = 3 Often = 4 Very Often = 5 1. I feel run down and drained of physical or emotional energy.

2. I have negative thoughts about my job.

3. I am harder and less sympathetic with people than perhaps they deserve.

4. I am easily irritated by small problems, or by my co-workers and team.

5. I feel misunderstood or unappreciated by my co-workers.

6. I feel that I have no one to talk to.

7. I feel that I am achieving less than I should.

8. I feel under an unpleasant level of pressure to succeed.

9. I feel I am not getting what I want out of my job.

10. I feel that I am in the wrong organization or the wrong profession.

11. I am frustrated with parts of my job.

12. I feel that organizational politics or bureaucracy frustrate my ability to do a good job.

13. I feel that there is more work to do than I practically have the ability to do.

14. I feel that I do not have time to do many of the things that are important to do a good quality job.

15. I find that I do not have time to plan as much as I would like to.

Score

Comment

15-18

No sign of burnout

19-32

Little sign of burnout, unless some factors are particularly severe

34-49

Be careful- you may be at risk of burnout, particularly if several scores are high

50-59

You are at severe risk of burnout – do something about this urgently

60-75

You are at very severe risk of burnout – do something about this urgently

© Mind Tools from Emerald Works Limited 2020. All rights reserved.

This self-test is never a proper diagnosis. Always remember that this is just a simple tool for you to assume your condition. If you do not feel well, always remember to go see a doctor and take a proper diagnosis, even if the test result comes out fine.

To deal with Burnout syndrome, improving your work-life balance is the key. You need to find a place and time that you can fully relax and feel comfortable. Exercising your body helps with stress. Taking nutritional supplements is also important to fight against burnout. Seeking support from others helps too. Find anyone such as your co-workers, friends, family, or love ones for support and help.

Conclusion Although Burnout syndrome is still considered as a condition rather than a disease, it is becoming a threat to modern society especially after the outbreak of COVID-19 pandemic. The society is tired and ill. To relieve from work stress and burnout, keeping an eye on your own mental health is important. If you feel tired right now, stop what you are doing for just a minute and try to follow the suggestions mentioned above. Hope everyone who are suffering from burnout read my article and find a way to improve your quality of life. B 2021 VOL.19

33

FAREWELL

Seo Woo Park

Ji Hye Seo

Sang Soo Na

Sang Hee Lee

Dong Hwan Lee

Hee Youn Yang

Ji Youn Son

Jung Won Kim

Chae Hyun Lee

Beom Ju Cho

Min Gi Lee

Hyo Jeong Kim

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From Seo Woo Park to Everyone: It’s already been two years since I’ve been taking part as Bluevanguardian. Writing this farewell message is a bittersweet moment. Spending countless hours on top of busy schedules to ensure the magazine of the highest quality was challenging. Since it goes through a lot of processes before publication, it would not have been possible without support and assistance from colleagues. I express my sincere thanks to my fellow and senior Bluevanguardians.

From Ji Hye Seo to Everyone: It was a great honor to be a member of the Blue Vanguards, and I sincerely appreciate every single moments with my fellow journalists and designers. Writing articles was not easy at all, but now I am truly grateful to those priceless experiences since they made me grow up for last two years. Can’t wait to get our latest issue. Thank you all!

From Sang Soo Na to Everyone: It’s been a great honor to be a part of such a prestigious club. I could sharpen both my English skills and pharmaceutical insight only thanks to the Blue Vanguards. It was definitely one of the most valuable experiences in the first two years in Yonsei college of Pharmacy. Huge thanks to all of the members in the BV. From Sang Hee Lee to Everyone: It has been an honor working with great members for two years. I’ve learned a lot and I know Blue Vanguard will also be successful with new members. It’s time to move on but I wish that I don’t forget good memories in the BlueVanguard. Thank you and farewell, From Dong Hwan Lee to Everyone: At first, I thought writing articles in English is harsh, hard and impossible but I have done it thanks to my dear friends. Also I could have done it because of my brilliant and gorgeous brain (kidding LOL). Anyway, I think this farewell is not a forever one. BV will always stay with me in here, my warm heart. ;) From Hee Youn Yang to Everyone: Blue Vanguard has been my only in-school activity in this unanswered Corona situation. I’ve had a hard time writing articles for two years, but I’m also proud afterward. 9th generation friends won’t write articles anymore, but they’re going to practice and study for the national test. Everyone worked hard! Good luck for the rest of the time in yonsei~ From Ji Youn Son to Everyone: I can’t believe it’s already been 2 years since I joined Blue Vanguard. Honestly, It wasn’t easy with all the busy schoolwork going on. But I feel proud of our crew for having responsibility and endeavouring for a higher quality during this contactless era. The finished result always astonished me and taught me to appreciate working with others, as a team. So thank you to everyone at Blue Vanguard, and good luck!

From Jung Won Kim to Everyone: I just can not believe it is already time to say farewell Blue Vangard! It was so much pleasure to learn the way to write, design, cooperate with peers. I hope you guys also feel so, and enjoy being a part of the Blue Vangard. I send all my thanks to everyone!

From Chae Hyun Lee to Everyone: I’ve joined Blue Vanguard a few semesters late, but the 2 semesters that I’ve been in Blue Vanguard has been a wonderful experience for me. Not only have I learnt how to write a scientific article for the first time, but also learnt various viewpoints on different topics. It was an honour to be part of this group!

From Beom Ju Cho to Everyone: The Blue Vanguard is one of the precious memories that takes up half of my Yonsei college of Pharmacy life. In the meantime, my InDesign experience has improved thanks to the BV members. It was a pleasure and thank you again.

Good luck in the future of the BV. From Min Gi Lee to Everyone: It was an honor to work in the Blue Vanguard design team for the past two years. Thank you to all the Blue Vanguard members for helping me fill my shortcomings. Good luck for all your life.

From Hyo Jeong Kim to Everyone: Blue Vanguard was the first place I was able to learn design and see my designs on a published platform. The Blue Vanguard provided me with experience for further challenges, and I believe BV will keep providing opportunities for future students. I hope all BV members are able to remember their experiences with a smile.

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MEMBERS #Journalist Editor In Chief: Yoon Zoo Gee

Vice Editor In Chief: Ok Yoon Kim

Copy Manager: Young Eun Choi Dong Hyeon Kim

Ji Hye Seo

Sang Hee Lee

Aran Kim

Ji Youn Son

Chae Hyun Lee

Jung Won Kim

Hee Youn Yang

Dong Hwan Lee

Sang Soo Na

Seo Woo Park

Ga Young Lee

Beon Ju Cho

Min Gi Lee

Hyo Jeong Kim

Hee Do Yang

Dae Hyun Kim

#Designer Design Manager: Ji Hyun Kim

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