Relationship between Handgrip Strength and Low-grade Inflammation in Older Adults with Depression

Objective@#The relationship among physical functional decline, low-grade inflammation, and depression remains unclear. The aim of this study was to examine the association between hand grip strength (HGS) and high-sensitivity C-reactive protein (hs-CRP) in a large sample with depression. @*Methods@#This study used data obtained from a representative Korean sample of 9,402 people who participated in the seventh Korean National Health and Nutrition Examination Survey. Physical function was assessed using a digital grip strength dynamometer. Depression was identified using a cutoff of 5 on the Patient Health Questionnaire-9 (PHQ-9), and high hs-CPR level was defined as ≥ 3.0 mg/L. @*Results@#In older adults (≥ 60 years) with depression, 43.8% of those with high hs-CRP levels had low HGS, compared to 21.8% of those with hs-CRP levels ＜ 3.0 mg/L (p = 0.002). Multivariate analysis revealed that, after adjustments for potentially confounding factors, high hs-CRP was independently associated with lower HGS (B = −2.25; 95% confidence interval = −4.49 to −0.02) in older adults with depression, but not in younger or middle-aged adults with depression. @*Conclusion@#These findings suggest a significant correlation between physical functional decline and low-grade inflammation in older adults with depression.

Associations between Intraocular Pressure and Systemic Parameters according to the KNHNES 2008-2011

PURPOSE: In this study, we evaluated the associations between intraocular pressure (IOP) and systemic and socioeconomic factors. METHODS: A population-based cross-sectional study using a nation-wide, stratified, multistage, clustered sampling method included 15,421 subjects aged ≥20 years with no history of ocular surgery or glaucoma who participated in the Korean National Health and Nutritional Examination Survey 2008-2011. RESULTS: Univariate regression analyses showed statistically significant linear relationships between IOP and body mass index (BMI), smoking status, heavy drinking, systolic blood pressure, fasting blood glucose, total cholesterol, triglycerides, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), metabolic syndrome (p < 0.001, respectively), low density lipoprotein cholesterol (p = 0.003), refractive error (p < 0.001), and office work (p = 0.029). In addition, analysis of variance (ANOVA) showed statistically significant differences in IOP and refraction according to occupation (p < 0.001, all). CONCLUSIONS: We concluded that increased IOP was associated with age, BMI, heavy drinking, systolic blood pressure, total cholesterol, and refraction. There were statistically significant differences in IOP and refraction according to occupation.

Platelet Indices Are Associated with Disease Activity Scores and the Severity of Sacroiliitis on Magnetic Resonance Imaging in Axial Spondyloarthritis Patients

OBJECTIVE: To investigate the associations among platelet indices, disease activity scores, and inflammatory markers in axial spondyloarthritis, and to determine the relation between platelet indices and inflammation measured on magnetic resonance imaging (MRI). METHODS: The study included 161 patients who fulfilled Assessment of Spondyloarthritis International Society criteria. Platelet indices such as mean platelet volume (MPV), plateletcrit (PCT), platelet large cell ratio (PLCR), and platelet distribution width (PDW) were measured. Ninety patients underwent sacroiliac (SI) MRI at baseline. Bone marrow edema (BME) and erosion on MRI were scored using the SPondyloArthritis Research Consortium of Canada (SPARCC) method. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Ankylosing Spondylitis Disease Activity Score (ASDAS) and spinal radiologic progression were also assessed. The associations among platelet indices and disease activity scores and inflammatory markers were evaluated. RESULTS: Of the 161 patients, 130 (81%) were male. MPV, PLCR, and PDW were negatively associated with ASDAS and inflammatory marker expression, whereas PCT was positively associated with these parameters. MPV, PLCR, and PDW were negatively associated with BME and erosion scores on SI MRI. However, platelet indices were not associated with the BASDAI and BASFI. The mean erythrocyte sedimentation rate, C-reactive protein, and BME and erosion scores were significantly higher in patients with low MPV. Changes in MPV, PCT, and PDW at baseline and after one year were associated with changes in ASDAS and inflammatory marker expression. CONCLUSION: Platelet indices are associated with ASDAS, inflammatory marker levels, and severity of BME and erosion measured on MRI.

Pulmonary hypertension in systemic lupus erythematosus: an independent predictor of patient survival

BACKGROUND/AIMS: We investigated whether transthoracic echocardiography-suspected pulmonary hypertension (PH) affects survival in systemic lupus erythematosus (SLE) patients and examined factors associated with PH occurrence and survival. METHODS: This retrospective single-center study included 154 Korean SLE patients fulfilling the American College of Rheumatology criteria (January 1995 to June 2013). Student t test, Mann-Whitney U test, Kaplan-Meier curves, and log-rank tests were used for comparisons. RESULTS: A total of 35 SLE patients with PH (SLE/PH+) and 119 without PH (SLE/PH-) were analyzed. Higher percentages of interstitial lung disease, Raynaud's phenomenon (RP), World Health Organization functional classification III/IV, and cardiomegaly were found in SLE/PH+ compared to SLE/PH-. Furthermore, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index was significantly higher in SLE/PH+ (2.46 +/- 1.245 vs. 1.00 +/- 1.235), whereas survival rates were significantly higher in SLE/PH- in log-rank tests (p = 0.001). In multivariate analysis, the adjusted mortality hazard ratio (HR) for SLE/PH+ patients was 3.10. Subgroup analysis demonstrated a higher percentage of lupus nephritis in the SLE/PH+ patients who died (p = 0.039) and low complement-3 levels (p = 0.007). In univariate analysis, the mortality HR for SLE/PH+ patients with lupus nephritis was 4.62, whereas the presence of RP decreased the mortality risk in multivariate analysis; adjusted HR, 0.10. CONCLUSIONS: PH is an independent factor predicting survival in SLE patients. The presence of lupus nephritis resulted in an increased trend for mortality, whereas coexistence of RP was associated with a better survival prognosis in SLE/PH+ patients.

S100A8/A9 as a biomarker for synovial inflammation and joint damage in patients with rheumatoid arthritis

S100A8 and S100A9 are major leukocyte proteins, known as damage-associated molecular patterns, found at high concentrations in the synovial fluid of patients with rheumatoid arthritis (RA). A heterodimeric complex of S100A8/A9 is secreted by activated leukocytes and binds to Toll-like receptor 4, which mediates downstream signaling and promotes inflammation and autoimmunity. Serum and synovial fluid levels of S100A8/A9 are markedly higher in patients with RA than in patients with osteoarthritis or miscellaneous inflammatory arthritis. Serum levels of S100A8/A9 are significantly correlated with clinical and laboratory markers of inflammation, such as C-reactive protein, erythrocyte sedimentation rate, rheumatoid factor, and the Disease Activity Score for 28 joints. Significant correlations have also been found between S100A8/A9 and radiographic and clinical assessments of joint damage, such as hand radiographs and the Rheumatoid Arthritis Articular Damage score. In addition, among known inflammatory markers, S100A8/A9 has the strongest correlation with total sum scores of ultrasonography assessment. Furthermore, baseline levels of S100A8/A9 are independently associated with progression of joint destruction in longitudinal studies and are responsive to change during conventional and biologic treatments. These findings suggest S100A8/A9 to be a valuable diagnostic and prognostic biomarker for RA.

A Case of Relapsing Granulomatosis with Polyangiitis Treated Successfully with Rituximab

Granulomatosis with polyangiitis (GPA) is a rare antineutrophil cytoplasmic antibody associated with systemic disease characterized by granulomas and vasculitis affecting small and medium vessels. Neurological manifestations in GPA are less frequent than classical manifestations, such as lung and kidney involvement, and cranial nerve palsies are much rarer. Cyclophosphamide and glucocorticoids have been conventionally administered as an initial induction immunosuppressive therapy for GPA. However, increasing evidence has demonstrated the efficacy and safety of rituximab, an anti-B cell monoclonal antibody, for the treatment of GPA. Herein, we describe a successful treatment of relapsing GPA with cranial nerve involvement using rituximab in a 56-year-old male patient who was previously treated with cyclophosphamide plus glucocorticoids.

Spontaneous Esophageal Perforation and Hypopharyngeal Abscess in Adult Dermatomyositis: A Case Report

In patients with dermatomyositis, chronic inflammation of the pharynx and esophagus results in coughing and difficulty in swallowing. These become important clinical symptoms, especially if they contribute to malnutrition or aspiration pneumonia. They can ultimately reduce the quality of life. In rare cases, if the symptoms worsen despite proper treatment, serious complications may arise, a reason to suspect an esophageal perforation or abscess. The authors report a case of dermatomyositis in an adult patient with rare complications of spontaneous esophageal perforation and hypopharyngeal abscess. The patient received non-surgical treatment and was able to resume oral intake of food.

The Effects of Antihypertensive Drugs on Bone Mineral Density in Ovariectomized Mice

The effects of several antihypertensive drugs on bone mineral density (BMD) and micro-architectural changes in ovariectomized (OVX) mice were investigated. Eight-week-old female C57/BL6 mice were used for this study. Three days after ovariectomy, mice were treated intraperitoneally with nifedipine (15 mg/kg), telmisartan (5 mg/kg), enalapril (20 mg/kg), propranolol (1 mg/kg) or hydrochlorothiazide (12.5 mg/kg) for 35 consecutive days. Uterine atrophy of all mice was confirmed to evaluate estrogen deficiency state. BMD and micro-architectural analyses were performed on tibial proximal ends by micro-computed tomography (micro-CT). When OVX mice with uterine atrophy were compared with mice without atrophy, BMD decreased (P < 0.001). There were significant differences in BMD loss between different antihypertensive drugs (P = 0.005). Enalapril and propranolol increased BMD loss in mice with atrophied uteri compared with control mice. By contrast, thiazide increased BMD in mice with uterine atrophy compared with vehicle-treated mice (P = 0.048). Thiazide (P = 0.032) and telmisartan (P = 0.051) reduced bone loss and bone fraction in mice with uterine atrophy compared with the control. Thiazide affects BMD in OVX mice positively. The reduction in bone loss by thiazide and telmisartan suggest that these drugs may benefit menopausal women with hypertension and osteoporosis.

The Effects of Antihypertensive Drugs on Bone Mineral Density in Ovariectomized Mice

The effects of several antihypertensive drugs on bone mineral density (BMD) and micro-architectural changes in ovariectomized (OVX) mice were investigated. Eight-week-old female C57/BL6 mice were used for this study. Three days after ovariectomy, mice were treated intraperitoneally with nifedipine (15 mg/kg), telmisartan (5 mg/kg), enalapril (20 mg/kg), propranolol (1 mg/kg) or hydrochlorothiazide (12.5 mg/kg) for 35 consecutive days. Uterine atrophy of all mice was confirmed to evaluate estrogen deficiency state. BMD and micro-architectural analyses were performed on tibial proximal ends by micro-computed tomography (micro-CT). When OVX mice with uterine atrophy were compared with mice without atrophy, BMD decreased (P < 0.001). There were significant differences in BMD loss between different antihypertensive drugs (P = 0.005). Enalapril and propranolol increased BMD loss in mice with atrophied uteri compared with control mice. By contrast, thiazide increased BMD in mice with uterine atrophy compared with vehicle-treated mice (P = 0.048). Thiazide (P = 0.032) and telmisartan (P = 0.051) reduced bone loss and bone fraction in mice with uterine atrophy compared with the control. Thiazide affects BMD in OVX mice positively. The reduction in bone loss by thiazide and telmisartan suggest that these drugs may benefit menopausal women with hypertension and osteoporosis.

Usefulness and Limitation of 2010 ACR/EULAR Classification Criteria in Korean Patients with Early RA

OBJECTIVE: The 2010 New American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria for rheumatoid arthritis (RA) was raised to identify patients with early RA and replaced the 1987 ACR classification criteria. The aims of this study are to assess the availability of new classification criteria and to evaluate its potential limitation. METHODS: A total of 408 patients with newly diagnosed RA were included from 13 secondary or tertiary hospitals in South Korea. The symptom duration was less than 12 months before the diagnosis of RA. RA was defined as either 1987 ACR classification criteria or new 2010 ACR/EULAR criteria. We compared the full details of both classification criteria. RESULTS: The mean symptom duration was 5.1 months. The majority (76.2%) of the patients were female. Two hundred and seventy three patients (66.9%) fulfilled both of the 2010 and 1987 classification criteria. Forty-seven (14.7%) of the 320 patients fulfilling the 1987 criteria did not fulfill the new classification criteria. On the other hand, eighty-eight (24.4%) of the 361 patients fulfilling the 2010 ACR/EULAR classification criteria did not fulfill the 1987 ACR criteria. Thirty-six (55.4%) of the 65 patient with seronegative RA failed to meet the 2010 classification criteria. In case of seropositive RA (n=343), 85 additional patients (24.8%) could be diagnosed as RA using new classification criteria. CONCLUSION: The new 2010 ACR/EULAR classification criteria enable physicians to diagnose more patients with early RA via the help of serology. However, the sensitivity for the diagnosis of seronegative RA is projected to decrease.

Gender Differences in Clinical Features and Anti-TNF Agent Use in Korean Ankylosing Spondylitis Patients

OBJECTIVE: The aim of this study was to assess the gender differences in the clinical presentation and treatment patterns between Korean women and men with ankylosing spondylitis (AS). METHODS: We retrospectively analyzed the data from extensive clinical assessments of 721 patients (162 women and 559 men) with AS, who were diagnosed at Seoul St. Mary's Hospital, between January 2000 and September 2009. Clinical data, regarding the disease onset, disease duration, clinical presentations, status of human leukocyte antigen (HLA)-B27, and bone mineral density, were determined using a dual-energy X-ray absorptiometry (DEXA). Finally, we analyzed the medical treatments prescribed for these patients. RESULTS: The ratio of men to women was 3.45:1. Compared to men, women were older at the time of diagnosis, had shorter disease durations, and were diagnosed in earlier stages of the disease. More women had a history of uveitis at diagnosis than men. Back pain was the main presenting symptom, and its prevalence was the same in both genders. Fewer women showed cervical and thoracic axial involvement than men. Initially, more women had wrist and hand pain than men; however, at some point, peripheral arthritis development was equally likely in both genders. Women experienced shoulder pain, during the disease course, more often thanmen. On the other hand, men presented with knee and hip pain more often than women. Sulfasalazine and anti-TNF agents were more often prescribed to women. CONCLUSION: The presentation and progression of AS showed a difference between women and men. Because of these differences, AS should be considered when a women presents with peripheral arthritis or uveitis in the early stage of the disease.

A Case of Polyarteritis Nodosa Manifesting as a Neuropathy Following Influenza Infection

Polyarteritis nodosa (PAN) is a necrotizing vasculitis of the medium-sized arteries. The symptoms and signs of PAN include purpuric skin lesions, mononeuritis multiplex, symptoms of mesenteric ischemia, and renal involvement. We report the first case of PAN manifesting as a neuropathy after influenza infection in Korea. A 68-year-old woman had fever, myalgia, hyperesthesia of both hand and foot, and lower extremity weakness. EMG findings showed severe sensorimotor polyneuropathy, such as multiple mononeuritis. A sural nerve biopsy showed vasculitis and Influenza A (H1N1) were positive. Our patient was treated by glucocorticoid and oral cyclophosphamide, thereafter, symptoms and signs improved. No recurrence has been observed for five months.

The Incidence of Serious Infection among Rheumatoid Arthritis Patients Exposed to Tumor Necrosis Factor Antagonists / 대한류마티스학회지

OBJECTIVE: We wanted to investigate the incidence of serious infections among the rheumatoid arthritis (RA) patients who were treated with tumor necrosis factor alpha (TNF-alpha) antagonists. METHODS: We enrolled the 175 RA patients who were treated with TNF-alpha antagonists for at least 3 months during February 2003 to July 2008, and these patients were in the SMART-b cohort of Kangnam St. Mary's hospital. Patients were prescribed infliximab, etanercept or adalimumab. The data was retrospectively collected. RESULTS: The incidence of serious infections among the RA patients treated with TNF-alpha was significantly increased according to the survival analysis, as compared with that of those patient treated with conventional DMARDs (p<0.01). The most common serious infection was pneumonia. There was no significant difference in the incidence of serious infections among the three TNF-alpha antagonists used in this study (p=0.96). But the serious infections occurred more often in the patients who received more than 10 mg methotrexate (MTX) per week (p=0.02). CONCLUSION: RA patients treated with TNF-alpha antagonists had a higher incidence of serious infection. Therefore, close monitoring for serious infection is needed for RA patients who are receiving TNF-alpha antagonists.

The Incidence of Serious Infection among Rheumatoid Arthritis Patients Exposed to Tumor Necrosis Factor Antagonists / 대한류마티스학회지

OBJECTIVE: We wanted to investigate the incidence of serious infections among the rheumatoid arthritis (RA) patients who were treated with tumor necrosis factor alpha (TNF-alpha) antagonists. METHODS: We enrolled the 175 RA patients who were treated with TNF-alpha antagonists for at least 3 months during February 2003 to July 2008, and these patients were in the SMART-b cohort of Kangnam St. Mary's hospital. Patients were prescribed infliximab, etanercept or adalimumab. The data was retrospectively collected. RESULTS: The incidence of serious infections among the RA patients treated with TNF-alpha was significantly increased according to the survival analysis, as compared with that of those patient treated with conventional DMARDs (p<0.01). The most common serious infection was pneumonia. There was no significant difference in the incidence of serious infections among the three TNF-alpha antagonists used in this study (p=0.96). But the serious infections occurred more often in the patients who received more than 10 mg methotrexate (MTX) per week (p=0.02). CONCLUSION: RA patients treated with TNF-alpha antagonists had a higher incidence of serious infection. Therefore, close monitoring for serious infection is needed for RA patients who are receiving TNF-alpha antagonists.

Upregulation of Macrophage Migration Inhibitory Factor (MIF) Production by Engagement of Toll-like Receptor 3 (TLR3) on Fibroblast-like Synoviocyte (FLS) from Patients with Rheumatoid Arthritis / 대한류마티스학회지

OBJECTIVE: Rheumatoid arthritis (RA) is a chronic autoimmune disease. Macrophage migration inhibitory factor (MIF) has been shown to be an important pro-inflammatory cytokine in RA. The aim of this study was to determine if the engagement of toll-like receptor 3 (TLR3) induces the production of MIF in the fibroblast-like synoviocytes (FLS) of patients with RA. METHODS: The expression of inflammatory cytokines (e.g. MIF, IL-6, IL-1beta and TNFalpha) and toll-like receptors (e.g. TLR2, TLR3 and TLR4) in the synovial tissue were quantified by immunohistochemistry. FLS were isolated from the synovial tissues of patients with RA and stimulated with TLR-3 ligand polyI:C, in the presence of a neutralizing antibody against IL-6. The concentrations of MIF and IL-6 in the culture supernatants from the FLS were measured using sandwich ELISA. RESULTS: The engagement of TLR3 with PolyI:C increased the production of MIF in FLS. The stimulatory effect of these TLR ligands showed a dose-dependent trend. The combination of TLR3 and TLR4 synergistically increased the level of MIF and IL-6 production. The addition of neutralizing antibodies against IL-6 abrogated the stimulatory effect of the ligands of TLR3 and TLR4 on the production of MIF. CONCLUSION: These results show that TLR3 engagement stimulates the production of MIF and IL-6. Therefore, the TLRs help perpetuate of RA pathogenesis through production of MIF from the FLS in patients with RA, and might provide a new therapeutic approach for the treatment of rheumatoid arthritis.

A Case of Osmotic Demyelination Syndrome after Hemodialysis Treatment in a Uremic Patient with Severe Hyperosmolality / 대한신장학회잡지

Osmotic demyelination syndrome (ODS) is a distinctive clinical syndrome with characteristic MR features in the central pons (central pontine myelinolysis) and in other brain locations (extrapontine myelinolysis). Rapid correction of hyponatremia is associated with ODS, but hyperosmolality rarely causes it. Here we report a case of ODS developed in a hemodialysis patient with severe uremia and concomitant hyperosmolality. A 67-year-old male was presented with general weakness and dyspnea. Laboratory findings showed severe uremia (blood urea nitrogen, 167 mg/dL; serum creatinine, 15 mg/dL), hyperosmolality (336 mOsm/kg H2O), and normal range of sodium (145 mEq/L). After the first hemodialysis treatment, his consciousness was changed to lethargic state. We initially suspected dialysis disequilibrium syndrome, but the symptoms were aggravated. MRI showed edema in central pons and symmetrical extrapotine lesions in the subcortical white matter, lateral thalamus, and posterior capsule, consistent with ODS. In spite of aggressive measures including continuous renal replacement therapy, he died of sepsis at the 26th hospital day.

Clinical courses and risk factors for renal graft survival in renal retransplantation patients / 대한내과학회지

BACKGROUND: It has been reported that the results of second renal transplantation are inferior to that of first transplantation and affected by several factors. The purpose of this study is to suggest guidelines for successful retransplantion by evaluating the factors which might affect the clinical courses and graft survival rates in the second renal transplantation. METHODS: Between March 1969 and February 2005, 1476 kidneys were transplanted in Kangnam St Mary's hospital. Among these, 77 cases were retransplantation (72 cases were second transplantation, 5 cases were third transplantation). Especially for the second transplantation, we retrospectively analysed the clinical courses of grafted kidneys and sought the factors which might be related to the long term graft survival. RESULTS: Among second transplant patients, male were 52 cases, female were 20 cases. The mean age at retransplantation was 38.4+/-11 years. Living donor were 62 cases and cadaver donor were 10 cases. The mean duration between primary graft failure and second transplantation was 20.1+/-36 months. The 1 yr, 3 yr, 5 yr survival rates of the second grafts were 86.4%, 78%, 71% respectively, and it is not significantly inferior to that of total primary transplantation at our center. Multivariate analysis showed that the duration of the first graft survival and the postoperative recovery pattern significantly predicted graft survival in the second renal transplantation. CONCLUSIONS: This study suggests retransplantation can be considered for patients who lost primary graft function. And the longer the duration of the first graft survival and the earlier the postoperative graft function recovery, the prognosis of retransplanted graft would be better.

A case of POEMS syndrome presenting as primary adrenocortical insufficiency associated with plasma cell myeloma / 대한내과학회지

POEMS syndrome is multisystemic disorder characterized polyneuropathy, organomegaly, endocrinopathies, monoclonal gammapathy. A 38 year-old man visited our hospital because of progressive general weakness, hyperpigmentation. We diagnosed him as idiopathic primary adrenal insufficiency. The symptoms of general weakness were improved after steroid replacement therapy. But after 6 months, he revisited ER with chief complaints of abdominal distension and edema in lower extremities. He had also polyneuropathy, hepatosplenomegaly, IgA light chain monoclonal gammopathy, hyperpigmentation and thickening of the skin. Bone marrow biopsy showed that the plasma cells, mainly mature forms, are about 40% of all nucleated elements and on tissue section. We think this is the first case of POEMS syndrome presenting as primary adrenocortical insufficiency in Korea, so we report the case with reviews of other literatures. And we recommend performing a rapid ACTH stimulation test in all POEMS syndrome in order to detect adrenal insufficiency.

Severe Acute Renal Failure Requiring Hemodialysis Treatment due to Malignant Hyperthermia / 대한신장학회잡지

Malignant hyperthermia is an inherited hypermetabolic syndrome, characterized by temperature elevation, muscle destruction, muscle rigidity, high oxygen consumption, and metabolic acidosis. It is usually triggered by anesthetic agents and neuromuscular relaxants. We present a case of malignant hyperthermia who developed rhabdomyolysis, acute renal failure, disseminated intravascular coagulopathy following an apparently uneventful general anesthesia. Anesthesia was induced with thiopental sodium and succinylcholine. He was successfully treated with dantrolene along with cardiopulmonary resuscitation and hemodialysis.