Frequency of Vertebral Compression Fractures in Spinal Osteoarthritis Patients in Relation to Bone Mineral Density / 대한류마티스학회지

OBJECTIVE: To investigate the association between bone mineral density (BMD) and osteoporotic compression fractures in radiographic spinal osteoarthritis (OA) patients. METHODS: Subjects were 382 female patients (ages 45 to 85) from outpatient clinic for osteoporosis and rheumatic diseases. BMD was measured at lumbar spine and hip by dual X-ray absorptiometry (Hologic QDR 2000). The standard anteroposterior and lateral plain radiographs of thoracic and lumbar spine were taken to define spinal OA and vertebral compression fractures. Radiographic spinal OA was defined by grade of disc degeneration and facet joint degeneration. Frequency of vertebral fractures was compared between spinal OA and control patients in relation to their BMD, age, weight, body mass index (BMI) and years post menopause. RESULTS: Higher proportion of fracture cases were observed in spinal OA patients than non-spinal OA patients (34.1%, 44/129 vs. 18.2%, 46/253, p<0.001) despite comparable mean BMD (0.836+/-0.152 vs. 0.834+/-0.185, p=0.89) and older mean age (65.8+/-8.5 vs. 57.8+/-10.3, p<0.001). In subjects of ages from 65 to 74, spinal OA patients showed significantly higher BMD than non-spinal OA patients (0.784+/-0.125 vs. 0.719+/-0.119, p=0.007), but the frequency of fractures seems to be higher than that of non-spinal OA patients (44.9%, 22/50 patients vs. 34%,19/55 patients, p=0.58). When all study subjects were stratified according to their spine BMD (normal, osteopenia, and osteoporosis), significantly higher proportion of vertebral compression fractures was noted in spinal OA than non-spinal OA patients in osteopenia group (38.5% vs. 13.5%, p<0.001). CONCLUSION: Higher BMD does not seem to be translated directly into decreased risk of osteoporotic compression fractures in spinal OA patients. Careful assessment of risk factors for osteoporotic fractures and newer methods for assessing bone strength in this group of patients are needed.

Expression of Receptor Activator of NF-kB Ligand (RANKL) and Formation of Osteoclast in Cultured Synovial Fibroblasts / 대한류마티스학회지

OBJECTIVE: A number of soluble factors,which play important role in the pathophysiology of rheumatoid synovitis are also known to be involved in osteoclast differentiation and activation through RANKL (Receptor activator of NF-kB ligand). To investigate the importance of RANKL in the pathogenesis of bone erosion in rheumatoid arthritis (RA) patients, we analyzed the expression of RANKL and Osteoprotegerin (OPG) and examined the formation of osteoclasts in rheumatoid synovial fibroblasts under the influence of various osteotropic factors. METHODS: Primary culture synoviocytes or fibroblast-like synoviocytes isolated from synovial tissues of 8 RA patients were cultured and treated with IL-1beta (2 ng/ml), TNF-alpha (2 ng/ml), INF-gamma(1000 micro/ml), IL-15 (10 ng/ml), IL-12 (10 ng/ml), dexamethasone (10(-9) M), PMA (10 ng/ml) or 1,25 (OH)2D3 (10(-9) M) for 18 hours. Expression RANKL or OPG mRNA was measured by semiquantitative RT-PCR within linear amplification condition. TRAP (+) MNC (tartrate resistant acid phosphatase-positive multinucleated cell) formation was induced from primary culture synoviocytes or in coculture system of synovial fibroblasts with PBMCs in the presence of M-CSF and 1,25 (OH)2D3. RESULTS: 1. The intensity of base-line expression was different from patient to patient. Primary culture synoviocytes and synovial fibroblasts express RANKL and OPG mRNA with decreasing intensity when they are passaged. 2. Expresssion of RANKL mRNA was significantly increased by 1,25 (OH)2D3 and IL-1beta (158.8+/-21% and 197.2+/-17% of controls, p<0.05 and p<0.005, respectively), while decreased significantly by dexamethasone (25.6+/-4.6% of controls, p<0.005). Expression of RANKL mRNA was significantly increased by IL-1beta and decreased by dexamethasone, in a dose- and time-dependant manner. 3. TRAP (+) MNCs are formed from primary culture synoviocytes or in coculture system of synovial fibroblasts and PBMC in the presence of M-CSF and 1,25 (OH)2D3. Dexamethasone clearly inhibited TRAP (+) MNCs formation from synovial cells. CONCLUSION: The regulatory mechanism for the expression of RANKL or OPG in rheumatoid synoviocytes might be different from that in bone marrow cells. Modulating the expression of these molecules could have potential therapeutic implication targeting bone destruction in RA.

A Case of Islets Cell Hyperplasia Diagnosed by Selective Arterial Calcium Stimulation Test / 대한내분비학회지

We report a 40-year-old female patient with clinical findings suggestive of insulinoma. Although imaging studies did not reveal any tumors in the pancreas, a selective arterial calcium stimulation test(SACI), procedurally simpler and more effective than transhepatic pancreatic venous sampling, was performed. And then near total pancreatectomy was carried out because the possibility of small insulinoma could not be completely excluded. Grossly, the surgically removed pancreas did not reveal any tumors. However, the pancreas exhibited islets cell hyperplasia. To our knowledge, this is the first reported authentic case in a Korean adult of islet-cell hyperplasia diagnosed by selective arterial calcium stimulation test.

Generalized Osteoporosis in Korean Rheumatoid Arthritis Patients / 대한류마티스학회지

OBJECTIVES: To assess the extent of generalized osteoporosis in Korean rheumatoid arthritis patients and evaluate the importance of disease activity, duration of disease, menopausal status, corticosteroid use and markers of bone metabolism. METHODS: Bone mineral density was measured by dual energy x-ray absorptiometry (DEXA) at 3 locations in 134 rheumatoid arthritis patients, aged 21~80 (57 premenopausal and 66 postmenopausal patients). Markers of bone metabolism were measured and assessed in relation to the disease activity and corticosteroid use. RESULTS: The mean age of the study population was 49 years and mean age of the menopause was 48.1+/-3.6 years. Decreased bone mineral density was observed at all 3 locations measured in the study population (Z-score -0.36, -0.14 and -0.66 for BMD of L-spine, femoral neck and femur Ward? triangle respectively). Fifty nine percent of the patients showed osteopenia (T-score <-1) and 13.4% showed T-score lower than -2.5. The best independent predictors of bone mass (stepweise multiple regression analysis) was body mass index, cortocosteroid use, and CRP in premenopausal patients and years post menopause, age, alkaline phosphatase and rheumatoid factor in postmenopausal patients. Urinary excretion of deoxypyridinoline was increased in both pre- and postmonopausal RA patients while serum osteocalcin level was normal in both groups. Deoxypyridinoline level was significantly correlated with CRP in premenopausal RA patients. CONCLUSION: Generalized osteoporosis is also prevalent in Korean rheumatoid arthritis patients. Bone metabolism appears to be uncoupled. Deoxypyridinoline correlated best with CRP and thus can provide a rational approach for selecting and treating patients with RA to reduce the risk of osteoporotic fracture.

Clinica Efficacy and Safety of Hyruan (Sodium Hyaluronate) in Patients with Osteoarthritis of the Knee / 대한류마티스학회지

OBJECTIVES: To assess the clinical efficacy and safety of Hyruan(sodium hyaluronate) in patients with osteoarthritis of the knee. METHODS: A 12-week open study of Hyruan was conducted in 48 patients with osteoarthritis(OA) of the knee. Hyruan was injected into knee joints weekly for 5 weeks. Clinical evaluations were performed using visual analog scale(VAS) for pain, Lequesne's index, tenderness and swollen joint counts weekly for the first 5 weeks and then monthly up to 3 months post-injection. RESULTS: Significant improvements in VAS, Lequesne's index, tenderness and swollen joint counts were noted from the first week and maintained until the end of 3 month follow-up period. At 3 months post-injection, 68.8% of patients had >20mm reduction in the VAS. The patients with Kellgren stage lIl showed significant response in VAS and Lequesne's index as patients with Kellgren stage I and II. The clinical improvement after treatment was slower in patients(n=16) with late(>5 years) OA than in patients(n=32) with early(<5 years) OA, but it was statistically significant in either groups, compared to baseline. There were no severe adverse reactions to Hyruan therapy and laboratory examinations revealed no evidence of toxicity. CONCLUSION: Hyruan has been shown to be effective and safe in the treatment of patients with osteoarthritis of the knee.

Fatal Pneumomediastinum and Subcutaneous Emphysema in a Patient with Dermatomyositis / 대한류마티스학회지

Dermatomyositis is a clinical entity characterized by a distinctive cutaneous rash and inflammatory myopathy. In this disorder, the pneumomediastinum is quite a rare complication and is assumed to result from air leakage due to vasculitis, lung fibrosis or rarely after bronchoscopic lung biopsy and pulmonary function test. We describe patient with dermatomyositis who developed pneumomediastinum, pneumothorax and massive subcutaneous emphysema after pulmonary function test. She died due to respiratory failure. We think that careful observation is required in performing PFT in dermatomyositis patients with presumed interstitial lung diseases.