Clinical Course and Outcomes of 3,060 Patients with Coronavirus Disease 2019 in Korea, January-May 2020.

BACKGROUND: The fatality rate of patients with coronavirus disease 2019 (COVID-19) varies among countries owing to demographics, patient comorbidities, surge capacity of healthcare systems, and the quality of medical care. We assessed the clinical outcomes of patients with COVID-19 during the first wave of the epidemic in Korea. METHODS: Using a modified World Health Organization clinical record form, we obtained clinical data for 3,060 patients with COVID-19 treated at 55 hospitals in Korea. Disease severity scores were defined as: 1) no limitation of daily activities; 2) limitation of daily activities but no need for supplemental oxygen; 3) supplemental oxygen via nasal cannula; 4) supplemental oxygen via facial mask; 5) non-invasive mechanical ventilation; 6) invasive mechanical ventilation; 7) multi-organ failure or extracorporeal membrane oxygenation therapy; and 8) death. Recovery was defined as a severity score of 1 or 2, or discharge and release from isolation. RESULTS: The median age of the patients was 43 years of age; 43.6% were male. The median time from illness onset to admission was 5 days. Of the patients with a disease severity score of 3-4 on admission, 65 (71.5%) of the 91 patients recovered, and 7 (7.7%) died due to illness by day 28. Of the patients with disease severity scores of 5-7, 7 (19.5%) of the 36 patients recovered, and 8 (22.2%) died due to illness by day 28. None of the 1,324 patients who were < 50 years of age died; in contrast, the fatality rate due to illness by day 28 was 0.5% (2/375), 0.9% (2/215), 5.8% (6/104), and 14.0% (7/50) for the patients aged 50-59, 60-69, 70-79, and ≥ 80 years of age, respectively. CONCLUSION: In Korea, almost all patients of < 50 years of age with COVID-19 recovered without supplemental oxygen. In patients of ≥ 50 years of age, the fatality rate increased with age, reaching 14% in patients of ≥ 80 years of age.

Salivary cortisol levels, but not salivary α-amylase levels, are elevated in patients with rheumatoid arthritis irrespective of depression.

OBJECTIVES: Stress is recognized as an important factor in the etiology of rheumatoid arthritis (RA). Therefore, we explored multiple aspects of stress in RA patients. METHODS: Salivary cortisol and α-amylase levels were measured as markers of the hypothalamic-pituitary-adrenal axis activity and sympatho-adrenomedullary system activity, respectively. Depression was assessed by the Beck Depression Inventory (BDI) and short-term analysis of the heart rate variability (HRV) was performed to evaluate the autonomic nervous system. RESULTS: The salivary cortisol levels of the RA patients were significantly higher than those of the normal controls (NC; 0.12 ± 0.162 µg/dL vs. 0.068 ± 0.052 µg/dL, P = 0.006). There was no difference in salivary α-amylase levels between the RA and the NC. The BDI levels of the RA patients were significantly higher than the NC (13.7 ± 8.9 vs. 6.4 ± 6.9, P < 0.001). Depression was more prevalent in RA patients than in the NC. The salivary cortisol levels were still significantly higher in the RA than the NC after controlling BDI by logistic regression analysis (P = 0.002). There was no significant difference in the HRV of RA patients and the NC. The evaluation of relationship between stress measures and disease activity markers of RA revealed that only BDI was positively correlated with the visual analogue pain scale. CONCLUSION: Salivary cortisol levels and the BDI of RA patients were higher than those of the NC, and elevated salivary cortisol levels were independent of depression. However, the level of stress may not be correlated with disease activity in RA.

Autoantibodies to C-reactive protein in incomplete lupus and systemic lupus erythematosus.

OBJECTIVE: Anti-C-reactive protein (CRP) antibodies have been described in patients with systemic lupus erythematosus (SLE). We investigated the potential of the anti-CRP antibody as a marker for disease activity in SLE patients and as a predictor of progression to SLE in patients with incomplete lupus. METHODS: Immunoglobulin G anti-CRP antibody levels were measured using an enzyme-linked immunosorbent assay. RESULTS: Patients with incomplete lupus exhibited clinical and immunologic characteristics different from those in SLE patients: no serositis and alopecia, more common oral ulcers and arthritis, lower disease activity index, lower positivity for antinuclear and anti-double-strand DNA antibodies, and higher complement levels. Anti-CRP antibody levels were higher in SLE patients (35.6 [35.1] AU) than in patients with incomplete lupus (23.1 [25.8] AU, P = 0.016) and normal controls (21.0 [14.3] AU, P < 0.001). Anti-CRP antibody was significantly higher in SLE patients with arthritis and correlated with disease activity markers, including antichromatin antibody. However, no difference in anti-CRP antibody levels was observed between patients with incomplete lupus that progressed to SLE and those whose did not. CONCLUSION: These data suggest that anti-CRP antibodies can neither be used as biomarkers in SLE nor predict SLE progression in patients with incomplete lupus.

C-reactive protein is a more sensitive and specific marker for diagnosing bacterial infections in systemic lupus erythematosus compared to S100A8/A9 and procalcitonin.

OBJECTIVE: C-reactive protein (CRP), S100A8/A9, and procalcitonin have been suggested as markers of infection in patients with systemic lupus erythematosus (SLE). We investigated the clinical significance of these factors for indication of infection in SLE. METHODS: Blood samples were prospectively collected from 34 patients with SLE who had bacterial infections and 39 patients with SLE who had disease flares and no evidence of infection. A second set of serum samples was collected after the infections or flares were resolved. RESULTS: CRP levels of SLE patients with infections were higher than those with flares [5.9 mg/dl (IQR 2.42, 10.53) vs 0.06 mg/dl (IQR 0.03, 0.15), p < 0.001] and decreased after the infection was resolved. S100A8/A9 and procalcitonin levels of SLE patients with infection were also higher [4.69 µg/ml (IQR 2.25, 12.07) vs 1.07 (IQR 0.49, 3.05) (p < 0.001) and 0 ng/ml (IQR 0-0.38) vs 0 (0-0) (p < 0.001), respectively]; these levels were also reduced once the infection disappeared. In the receiver-operating characteristics analysis of CRP, S100A8/A9, and procalcitonin, the area under the curve was 0.966 (95% CI 0.925-1.007), 0.732 (95% CI 0.61-0.854), and 0.667 (95% CI 0.534-0.799), respectively. CRP indicated the presence of an infection with a sensitivity of 100% and a specificity of 90%, with a cutoff value of 1.35 mg/dl. CONCLUSION: Our data suggest that CRP is the most sensitive and specific marker for diagnosing bacterial infections in SLE.

Induction of remission is difficult due to frequent relapse during tapering steroids in Korean patients with polymyalgia rheumatica.

Polymyalgia rheumatica is an inflammatory disease affecting elderly and involving the shoulder and pelvic girdles. No epidemiological study of polymyalgia rheumatica was conducted in Korea. We retrospectively evaluated patients with polymyalgia rheumatica followed up at the rheumatology clinics of 10 tertiary hospitals. In total 51 patients, 36 patients (70.6%) were female. Age at disease onset was 67.4 yr. Twenty-three patients (45.1%) developed polymyalgia rheumatica in winter. Shoulder girdle ache was observed in 45 patients (90%) and elevated erythrocyte sedimentation rate (> 40 mm/h) in 49 patients (96.1%). Initial steroid dose was 23.3 mg/d prednisolone equivalent. Time to normal erythrocyte sedimentation rate was 4.1 months. Only 8 patients (15.7%) achieved remission. Among 41 patients followed up, 28 patients (68.3%) had flare at least once. Number of flares was 1.5 ± 1.6. The frequency of flare was significantly lower in patients with remission (P = 0.02). In Korea, polymyalgia rheumatica commonly develops during winter. Initial response to steroid is fairly good, but the prognosis is not benign because remission is rare with frequent relapse requiring long-term steroid treatment.

Impact of myocardial perfusion on left atrial remodeling following primary angioplasty for acute myocardial infarction.

OBJECTIVES: To investigate the impact of myocardial perfusion on left atrial remodeling and its determinants after primary percutaneous coronary intervention for acute myocardial infarction. BACKGROUND: Left atrial volume is an important predictor of morbidity and mortality in acute myocardial infarction, while thrombolysis in myocardial infarction (TIMI) myocardial perfusion (TMP) grade is an angiographic index associated with infarct size and mortality. As yet, however, the relationship between TMP grade and left atrial remodeling has not been investigated. METHODS: Conventional transthoracic echocardiography was performed in 105 patients (55+/-13 years old, 92 men) with acute myocardial infarction within 24 h and after 6 months (mean 9+/-4, range 6-29 months) following successful primary percutaneous coronary intervention. Absolute left atrial volume was calculated using an elliptical model. Myocardial perfusion was evaluated, using TMP grade, by visual assessment on the coronary angiogram. Patients were divided into three groups on the basis of myocardial perfusion status, as TMP 0/1 (n=36), TMP 2 (n=36) and TMP 3 (n=33). RESULTS: No difference was observed between baseline and follow-up left atrial volumes in the overall study population (42.5+/-16.1 vs. 43.5+/-17.4 ml, P=0.519). As regards TMP grade, follow-up left atrial volume significantly increased in the TMP 0/1 group (43+/-17 vs. 54.6+/-1.1 ml, P<0.001) and significantly decreased in the TMP 3 group (42.9+/-15.7 vs. 35.5+/-12.2 ml, P=0.001) compared with initial values. No change was observed in left atrial volume in the TMP 2 group. Multivariate analysis showed that TMP grade (P<0.001) and anterior location of myocardial infarction (P<0.001) were independent determinants of left atrial remodeling. CONCLUSIONS: These results suggest that poor myocardial perfusion and anterior location of myocardial infarction can affect left atrial remodeling in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. It appears that adequate myocardial perfusion is crucial to prevent left atrial remodeling, a poor prognostic factor in acute myocardial infarction.