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Astragalin Inhibits Cigarette Smoke-Induced Pulmonary Thrombosis and Alveolar Inflammation and Disrupts PAR Activation and Oxidative Stress-Responsive MAPK-Signaling
Epidemiological evidence shows that smoking causes a thrombophilic milieu that may play a role in the pathophysiology of chronic obstructive pulmonary disease (COPD) as well as pulmonary thromboembolism. The increased nicotine level induces a prothrombotic status and abnormal blood coagulation in sm...
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Published in: | International journal of molecular sciences 2021-04, Vol.22 (7), p.3692 |
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creator | Kim, Yun-Ho Kang, Min-Kyung Lee, Eun-Jung Kim, Dong Yeon Oh, Hyeongjoo Kim, Soo-Il Oh, Su Yeon Na, Woojin Shim, Jae-Hoon Kang, Il-Jun Kang, Young-Hee |
description | Epidemiological evidence shows that smoking causes a thrombophilic milieu that may play a role in the pathophysiology of chronic obstructive pulmonary disease (COPD) as well as pulmonary thromboembolism. The increased nicotine level induces a prothrombotic status and abnormal blood coagulation in smokers. Since several anticoagulants increase bleeding risk, alternative therapies need to be identified to protect against thrombosis without affecting hemostasis. Astragalin is a flavonoid present in persimmon leaves and green tea seeds and exhibits diverse activities of antioxidant and anti-inflammation. The current study investigated that astragalin attenuated smoking-induced pulmonary thrombosis and alveolar inflammation. In addition, it was explored that molecular links between thrombosis and inflammation entailed protease-activated receptor (PAR) activation and oxidative stress-responsive mitogen-activated protein kinase (MAPK)-signaling. BALB/c mice were orally administrated with 10-20 mg/kg astragalin and exposed to cigarette smoke for 8 weeks. For the in vitro study, 10 U/mL thrombin was added to alveolar epithelial A549 cells in the presence of 1-20 µM astragalin. The cigarette smoking-induced the expression of PAR-1 and PAR-2 in lung tissues, which was attenuated by the administration of ≥10 mg/kg astragalin. The oral supplementation of ≥10 mg/kg astragalin to cigarette smoke-challenged mice attenuated the protein induction of urokinase plasminogen activator, plasminogen activator inhibitor-1and tissue factor, and instead enhanced the induction of tissue plasminogen activator in lung tissues. The astragalin treatment alleviated cigarette smoke-induced lung emphysema and pulmonary thrombosis. Astragalin caused lymphocytosis and neutrophilia in bronchoalveolar lavage fluid due to cigarette smoke but curtailed infiltration of neutrophils and macrophages in airways. Furthermore, this compound retarded thrombin-induced activation of PAR proteins and expression of inflammatory mediators in alveolar cells. Treating astragalin interrupted PAR proteins-activated reactive oxygen species production and MAPK signaling leading to alveolar inflammation. Accordingly, astragalin may interrupt the smoking-induced oxidative stress-MAPK signaling-inflammation axis via disconnection between alveolar PAR activation and pulmonary thromboembolism. |
doi_str_mv | 10.3390/ijms22073692 |
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The increased nicotine level induces a prothrombotic status and abnormal blood coagulation in smokers. Since several anticoagulants increase bleeding risk, alternative therapies need to be identified to protect against thrombosis without affecting hemostasis. Astragalin is a flavonoid present in persimmon leaves and green tea seeds and exhibits diverse activities of antioxidant and anti-inflammation. The current study investigated that astragalin attenuated smoking-induced pulmonary thrombosis and alveolar inflammation. In addition, it was explored that molecular links between thrombosis and inflammation entailed protease-activated receptor (PAR) activation and oxidative stress-responsive mitogen-activated protein kinase (MAPK)-signaling. BALB/c mice were orally administrated with 10-20 mg/kg astragalin and exposed to cigarette smoke for 8 weeks. For the in vitro study, 10 U/mL thrombin was added to alveolar epithelial A549 cells in the presence of 1-20 µM astragalin. The cigarette smoking-induced the expression of PAR-1 and PAR-2 in lung tissues, which was attenuated by the administration of ≥10 mg/kg astragalin. The oral supplementation of ≥10 mg/kg astragalin to cigarette smoke-challenged mice attenuated the protein induction of urokinase plasminogen activator, plasminogen activator inhibitor-1and tissue factor, and instead enhanced the induction of tissue plasminogen activator in lung tissues. The astragalin treatment alleviated cigarette smoke-induced lung emphysema and pulmonary thrombosis. Astragalin caused lymphocytosis and neutrophilia in bronchoalveolar lavage fluid due to cigarette smoke but curtailed infiltration of neutrophils and macrophages in airways. Furthermore, this compound retarded thrombin-induced activation of PAR proteins and expression of inflammatory mediators in alveolar cells. Treating astragalin interrupted PAR proteins-activated reactive oxygen species production and MAPK signaling leading to alveolar inflammation. Accordingly, astragalin may interrupt the smoking-induced oxidative stress-MAPK signaling-inflammation axis via disconnection between alveolar PAR activation and pulmonary thromboembolism.</description><identifier>ISSN: 1422-0067</identifier><identifier>ISSN: 1661-6596</identifier><identifier>EISSN: 1422-0067</identifier><identifier>DOI: 10.3390/ijms22073692</identifier><identifier>PMID: 33916310</identifier><language>eng</language><publisher>Switzerland: MDPI AG</publisher><subject>Alveoli ; Animals ; Anticoagulants ; Antioxidants ; Attenuation ; Blood clots ; Blood coagulation ; Blood platelets ; Bronchus ; Chronic obstructive pulmonary disease ; Cigarette smoke ; Cigarette smoking ; Cigarette Smoking - adverse effects ; Cigarettes ; Drug Evaluation, Preclinical ; Drugs ; Emphysema ; Epidemiology ; Flavonoids ; Green tea ; Hemostasis ; Hemostatics ; Inflammation ; Inflammatory diseases ; Kaempferols - pharmacology ; Kaempferols - therapeutic use ; Kinases ; Leukocytes (neutrophilic) ; Lung diseases ; Lungs ; Lymphocytosis ; Macrophages ; Male ; MAP kinase ; MAP Kinase Signaling System - drug effects ; Mice ; Mice, Inbred BALB C ; Neutrophilia ; Neutrophils ; Nicotine ; Obstructive lung disease ; Oral administration ; Oxidative Stress ; Pathophysiology ; Polyphenols ; Protein kinase ; Proteins ; Pulmonary arteries ; Pulmonary Embolism - etiology ; Pulmonary Embolism - prevention & control ; Pulmonary Emphysema - prevention & control ; Reactive oxygen species ; Receptors, Proteinase-Activated - antagonists & inhibitors ; Seeds ; Smoking ; Thrombin ; Thromboembolism ; Thrombosis ; Tobacco smoke ; Urokinase</subject><ispartof>International journal of molecular sciences, 2021-04, Vol.22 (7), p.3692</ispartof><rights>2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2021 by the authors. 2021</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c412t-70376b4986b3db98853f79222c256c59b71a36d89ddc1c9187b3c8641cb45aa13</citedby><cites>FETCH-LOGICAL-c412t-70376b4986b3db98853f79222c256c59b71a36d89ddc1c9187b3c8641cb45aa13</cites><orcidid>0000-0003-0314-5195 ; 0000-0003-2039-7968</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.proquest.com/docview/2548769622/fulltextPDF?pq-origsite=primo$$EPDF$$P50$$Gproquest$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.proquest.com/docview/2548769622?pq-origsite=primo$$EHTML$$P50$$Gproquest$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,885,25751,27922,27923,37010,37011,38514,43893,44588,53789,53791,74182,74896</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/33916310$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Kim, Yun-Ho</creatorcontrib><creatorcontrib>Kang, Min-Kyung</creatorcontrib><creatorcontrib>Lee, Eun-Jung</creatorcontrib><creatorcontrib>Kim, Dong Yeon</creatorcontrib><creatorcontrib>Oh, Hyeongjoo</creatorcontrib><creatorcontrib>Kim, Soo-Il</creatorcontrib><creatorcontrib>Oh, Su Yeon</creatorcontrib><creatorcontrib>Na, Woojin</creatorcontrib><creatorcontrib>Shim, Jae-Hoon</creatorcontrib><creatorcontrib>Kang, Il-Jun</creatorcontrib><creatorcontrib>Kang, Young-Hee</creatorcontrib><title>Astragalin Inhibits Cigarette Smoke-Induced Pulmonary Thrombosis and Alveolar Inflammation and Disrupts PAR Activation and Oxidative Stress-Responsive MAPK-Signaling</title><title>International journal of molecular sciences</title><addtitle>Int J Mol Sci</addtitle><description>Epidemiological evidence shows that smoking causes a thrombophilic milieu that may play a role in the pathophysiology of chronic obstructive pulmonary disease (COPD) as well as pulmonary thromboembolism. The increased nicotine level induces a prothrombotic status and abnormal blood coagulation in smokers. Since several anticoagulants increase bleeding risk, alternative therapies need to be identified to protect against thrombosis without affecting hemostasis. Astragalin is a flavonoid present in persimmon leaves and green tea seeds and exhibits diverse activities of antioxidant and anti-inflammation. The current study investigated that astragalin attenuated smoking-induced pulmonary thrombosis and alveolar inflammation. In addition, it was explored that molecular links between thrombosis and inflammation entailed protease-activated receptor (PAR) activation and oxidative stress-responsive mitogen-activated protein kinase (MAPK)-signaling. BALB/c mice were orally administrated with 10-20 mg/kg astragalin and exposed to cigarette smoke for 8 weeks. For the in vitro study, 10 U/mL thrombin was added to alveolar epithelial A549 cells in the presence of 1-20 µM astragalin. The cigarette smoking-induced the expression of PAR-1 and PAR-2 in lung tissues, which was attenuated by the administration of ≥10 mg/kg astragalin. The oral supplementation of ≥10 mg/kg astragalin to cigarette smoke-challenged mice attenuated the protein induction of urokinase plasminogen activator, plasminogen activator inhibitor-1and tissue factor, and instead enhanced the induction of tissue plasminogen activator in lung tissues. The astragalin treatment alleviated cigarette smoke-induced lung emphysema and pulmonary thrombosis. Astragalin caused lymphocytosis and neutrophilia in bronchoalveolar lavage fluid due to cigarette smoke but curtailed infiltration of neutrophils and macrophages in airways. Furthermore, this compound retarded thrombin-induced activation of PAR proteins and expression of inflammatory mediators in alveolar cells. Treating astragalin interrupted PAR proteins-activated reactive oxygen species production and MAPK signaling leading to alveolar inflammation. Accordingly, astragalin may interrupt the smoking-induced oxidative stress-MAPK signaling-inflammation axis via disconnection between alveolar PAR activation and pulmonary thromboembolism.</description><subject>Alveoli</subject><subject>Animals</subject><subject>Anticoagulants</subject><subject>Antioxidants</subject><subject>Attenuation</subject><subject>Blood clots</subject><subject>Blood coagulation</subject><subject>Blood platelets</subject><subject>Bronchus</subject><subject>Chronic obstructive pulmonary disease</subject><subject>Cigarette smoke</subject><subject>Cigarette smoking</subject><subject>Cigarette Smoking - adverse effects</subject><subject>Cigarettes</subject><subject>Drug Evaluation, Preclinical</subject><subject>Drugs</subject><subject>Emphysema</subject><subject>Epidemiology</subject><subject>Flavonoids</subject><subject>Green tea</subject><subject>Hemostasis</subject><subject>Hemostatics</subject><subject>Inflammation</subject><subject>Inflammatory diseases</subject><subject>Kaempferols - pharmacology</subject><subject>Kaempferols - therapeutic use</subject><subject>Kinases</subject><subject>Leukocytes (neutrophilic)</subject><subject>Lung diseases</subject><subject>Lungs</subject><subject>Lymphocytosis</subject><subject>Macrophages</subject><subject>Male</subject><subject>MAP kinase</subject><subject>MAP Kinase Signaling System - drug effects</subject><subject>Mice</subject><subject>Mice, Inbred BALB C</subject><subject>Neutrophilia</subject><subject>Neutrophils</subject><subject>Nicotine</subject><subject>Obstructive lung disease</subject><subject>Oral administration</subject><subject>Oxidative Stress</subject><subject>Pathophysiology</subject><subject>Polyphenols</subject><subject>Protein kinase</subject><subject>Proteins</subject><subject>Pulmonary arteries</subject><subject>Pulmonary Embolism - etiology</subject><subject>Pulmonary Embolism - prevention & control</subject><subject>Pulmonary Emphysema - prevention & control</subject><subject>Reactive oxygen species</subject><subject>Receptors, Proteinase-Activated - antagonists & inhibitors</subject><subject>Seeds</subject><subject>Smoking</subject><subject>Thrombin</subject><subject>Thromboembolism</subject><subject>Thrombosis</subject><subject>Tobacco smoke</subject><subject>Urokinase</subject><issn>1422-0067</issn><issn>1661-6596</issn><issn>1422-0067</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><sourceid>COVID</sourceid><sourceid>PIMPY</sourceid><recordid>eNpdkUtv1DAUhSMEoqWwY40isWFBwI_Ejw1SNLxGFHXUlrVlO56MB8cebGcEP4j_iYeWMrDy43w-vufeqnoKwSuMOXhtt1NCCFBMOLpXncIWoQYAQu8f7U-qRyltAUAYdfxhdVIeQoIhOK1-9ilHOUpnfb30G6tsTvXCjjKanE19NYWvpln6YdZmqFezm4KX8Ud9vYlhUiHZVEs_1L3bm-BkLBZrJ6dJZhv8b-WtTXHeFc9Vf1n3Otv9X-3iux3KaV--ydGk1FyatAs-HW4-96tPzZUd_aGy8XH1YC1dMk9u17Pqy_t314uPzfnFh-WiP290C1FuKMCUqJYzovCgOGMdXlOOENKoI7rjikKJycD4MGioOWRUYc1IC7VqOykhPqve3PjuZjWZQRtfmuPELtqppBZBWvGv4u1GjGEvGMCkRaAYvLg1iOHbbFIWk03aOCe9CXMSqEOAlc5TVtDn_6HbMMeS90C1jBJOECrUyxtKx5BSNOu7YiAQh_mL4_kX_NlxgDv4z8DxLy0jrtQ</recordid><startdate>20210401</startdate><enddate>20210401</enddate><creator>Kim, Yun-Ho</creator><creator>Kang, Min-Kyung</creator><creator>Lee, Eun-Jung</creator><creator>Kim, Dong Yeon</creator><creator>Oh, Hyeongjoo</creator><creator>Kim, Soo-Il</creator><creator>Oh, Su Yeon</creator><creator>Na, Woojin</creator><creator>Shim, Jae-Hoon</creator><creator>Kang, Il-Jun</creator><creator>Kang, Young-Hee</creator><general>MDPI AG</general><general>MDPI</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>COVID</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>K9.</scope><scope>M0S</scope><scope>M1P</scope><scope>M2O</scope><scope>MBDVC</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>Q9U</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0003-0314-5195</orcidid><orcidid>https://orcid.org/0000-0003-2039-7968</orcidid></search><sort><creationdate>20210401</creationdate><title>Astragalin Inhibits Cigarette Smoke-Induced Pulmonary Thrombosis and Alveolar Inflammation and Disrupts PAR Activation and Oxidative Stress-Responsive MAPK-Signaling</title><author>Kim, Yun-Ho ; Kang, Min-Kyung ; Lee, Eun-Jung ; Kim, Dong Yeon ; Oh, Hyeongjoo ; Kim, Soo-Il ; Oh, Su Yeon ; Na, Woojin ; Shim, Jae-Hoon ; Kang, Il-Jun ; Kang, Young-Hee</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c412t-70376b4986b3db98853f79222c256c59b71a36d89ddc1c9187b3c8641cb45aa13</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Alveoli</topic><topic>Animals</topic><topic>Anticoagulants</topic><topic>Antioxidants</topic><topic>Attenuation</topic><topic>Blood clots</topic><topic>Blood coagulation</topic><topic>Blood platelets</topic><topic>Bronchus</topic><topic>Chronic obstructive pulmonary disease</topic><topic>Cigarette smoke</topic><topic>Cigarette smoking</topic><topic>Cigarette Smoking - adverse effects</topic><topic>Cigarettes</topic><topic>Drug Evaluation, Preclinical</topic><topic>Drugs</topic><topic>Emphysema</topic><topic>Epidemiology</topic><topic>Flavonoids</topic><topic>Green tea</topic><topic>Hemostasis</topic><topic>Hemostatics</topic><topic>Inflammation</topic><topic>Inflammatory diseases</topic><topic>Kaempferols - pharmacology</topic><topic>Kaempferols - therapeutic use</topic><topic>Kinases</topic><topic>Leukocytes (neutrophilic)</topic><topic>Lung diseases</topic><topic>Lungs</topic><topic>Lymphocytosis</topic><topic>Macrophages</topic><topic>Male</topic><topic>MAP kinase</topic><topic>MAP Kinase Signaling System - drug effects</topic><topic>Mice</topic><topic>Mice, Inbred BALB C</topic><topic>Neutrophilia</topic><topic>Neutrophils</topic><topic>Nicotine</topic><topic>Obstructive lung disease</topic><topic>Oral administration</topic><topic>Oxidative Stress</topic><topic>Pathophysiology</topic><topic>Polyphenols</topic><topic>Protein kinase</topic><topic>Proteins</topic><topic>Pulmonary arteries</topic><topic>Pulmonary Embolism - 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The increased nicotine level induces a prothrombotic status and abnormal blood coagulation in smokers. Since several anticoagulants increase bleeding risk, alternative therapies need to be identified to protect against thrombosis without affecting hemostasis. Astragalin is a flavonoid present in persimmon leaves and green tea seeds and exhibits diverse activities of antioxidant and anti-inflammation. The current study investigated that astragalin attenuated smoking-induced pulmonary thrombosis and alveolar inflammation. In addition, it was explored that molecular links between thrombosis and inflammation entailed protease-activated receptor (PAR) activation and oxidative stress-responsive mitogen-activated protein kinase (MAPK)-signaling. BALB/c mice were orally administrated with 10-20 mg/kg astragalin and exposed to cigarette smoke for 8 weeks. For the in vitro study, 10 U/mL thrombin was added to alveolar epithelial A549 cells in the presence of 1-20 µM astragalin. The cigarette smoking-induced the expression of PAR-1 and PAR-2 in lung tissues, which was attenuated by the administration of ≥10 mg/kg astragalin. The oral supplementation of ≥10 mg/kg astragalin to cigarette smoke-challenged mice attenuated the protein induction of urokinase plasminogen activator, plasminogen activator inhibitor-1and tissue factor, and instead enhanced the induction of tissue plasminogen activator in lung tissues. The astragalin treatment alleviated cigarette smoke-induced lung emphysema and pulmonary thrombosis. Astragalin caused lymphocytosis and neutrophilia in bronchoalveolar lavage fluid due to cigarette smoke but curtailed infiltration of neutrophils and macrophages in airways. Furthermore, this compound retarded thrombin-induced activation of PAR proteins and expression of inflammatory mediators in alveolar cells. Treating astragalin interrupted PAR proteins-activated reactive oxygen species production and MAPK signaling leading to alveolar inflammation. Accordingly, astragalin may interrupt the smoking-induced oxidative stress-MAPK signaling-inflammation axis via disconnection between alveolar PAR activation and pulmonary thromboembolism.</abstract><cop>Switzerland</cop><pub>MDPI AG</pub><pmid>33916310</pmid><doi>10.3390/ijms22073692</doi><orcidid>https://orcid.org/0000-0003-0314-5195</orcidid><orcidid>https://orcid.org/0000-0003-2039-7968</orcidid><oa>free_for_read</oa></addata></record> |
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recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_8036420 |
source | NCBI_PubMed Central(免费); ProQuest - Publicly Available Content Database; Coronavirus Research Database |
subjects | Alveoli Animals Anticoagulants Antioxidants Attenuation Blood clots Blood coagulation Blood platelets Bronchus Chronic obstructive pulmonary disease Cigarette smoke Cigarette smoking Cigarette Smoking - adverse effects Cigarettes Drug Evaluation, Preclinical Drugs Emphysema Epidemiology Flavonoids Green tea Hemostasis Hemostatics Inflammation Inflammatory diseases Kaempferols - pharmacology Kaempferols - therapeutic use Kinases Leukocytes (neutrophilic) Lung diseases Lungs Lymphocytosis Macrophages Male MAP kinase MAP Kinase Signaling System - drug effects Mice Mice, Inbred BALB C Neutrophilia Neutrophils Nicotine Obstructive lung disease Oral administration Oxidative Stress Pathophysiology Polyphenols Protein kinase Proteins Pulmonary arteries Pulmonary Embolism - etiology Pulmonary Embolism - prevention & control Pulmonary Emphysema - prevention & control Reactive oxygen species Receptors, Proteinase-Activated - antagonists & inhibitors Seeds Smoking Thrombin Thromboembolism Thrombosis Tobacco smoke Urokinase |
title | Astragalin Inhibits Cigarette Smoke-Induced Pulmonary Thrombosis and Alveolar Inflammation and Disrupts PAR Activation and Oxidative Stress-Responsive MAPK-Signaling |
url | http://sfxeu10.hosted.exlibrisgroup.com/loughborough?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-14T12%3A49%3A44IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Astragalin%20Inhibits%20Cigarette%20Smoke-Induced%20Pulmonary%20Thrombosis%20and%20Alveolar%20Inflammation%20and%20Disrupts%20PAR%20Activation%20and%20Oxidative%20Stress-Responsive%20MAPK-Signaling&rft.jtitle=International%20journal%20of%20molecular%20sciences&rft.au=Kim,%20Yun-Ho&rft.date=2021-04-01&rft.volume=22&rft.issue=7&rft.spage=3692&rft.pages=3692-&rft.issn=1422-0067&rft.eissn=1422-0067&rft_id=info:doi/10.3390/ijms22073692&rft_dat=%3Cproquest_pubme%3E2548769622%3C/proquest_pubme%3E%3Cgrp_id%3Ecdi_FETCH-LOGICAL-c412t-70376b4986b3db98853f79222c256c59b71a36d89ddc1c9187b3c8641cb45aa13%3C/grp_id%3E%3Coa%3E%3C/oa%3E%3Curl%3E%3C/url%3E&rft_id=info:oai/&rft_pqid=2548769622&rft_id=info:pmid/33916310&rfr_iscdi=true |