The change of the COVID-19 pandemic on medical education in Korea: a national survey of medical schools

PURPOSE

This study aims to investigate how medical schools in Korea managed their academic affairs and student support in response to the coronavirus disease 2019 (COVID-19) pandemic and their plans for the post-COVID-19 era.

METHODS

An online survey was conducted, and a link to a questionnaire was distributed to all the administrators of the 40 medical schools in Korea. The final analysis data involved responses from 33 medical schools and 1,342 students. Frequency analysis, cross-tabulation analysis, Fisher's exact test, and one-way analysis of variance were applied for statistical analysis.

RESULTS

Regarding instruction methods, most medical schools in Korea transitioned from in-person learning to video-on-demand learning (51.5%) and real-time online learning (42.4%). Among the school leaders, 36.4% planned to continue offering online classes combined with in-person classes beyond the end of the pandemic. Among the students, the online class concentration and participation score was 3.0 points or lower, but the class understanding score was 3.6 points, above a moderate level.

CONCLUSION

Students cited the shorter times needed to attend school and being able to take classes repeatedly as advantages of online classes, and over one-third of medical schools intended to continue with a hybrid of in-person and online learning even after the COVID-19 pandemic restrictions end.

Successful emergency medical service training with virtual field trips using video during the COVID-19 pandemic: the Official Development Assistance Project in Uzbekistan

PURPOSE

The coronavirus disease 2019 pandemic saw many restrictions on the provision of emergency medical service (EMS) training through actual field trips (AFTs), requiring a search for alternatives. This study aimed to assess trainees' reactions to virtual field trips (VFTs) and determine the characteristics of instructional design for successful VFTs using edited videos and expert interviews.

METHODS

This study evaluated Uzbekistan trainees' reactions to the VFT of EMS training using questionnaires in three categories: satisfaction, relevance, and engagement. Factors of satisfaction and dissatisfaction were identified through open-ended questions.

RESULTS

A total of 286 trainees responded to the survey during 15 educational sessions conducted from 2020 to 2022. The trainees' responses to the VFT were positive. Overall mean scores were 4.65±0.49, 4.63±0.50, and 4.63±0.50 out of 5 points for satisfaction, relevance, and engagement, respectively. The trainees reported that the most interesting and helpful videos concerned the introduction of an EMS training curriculum and the observation of training facilities, such as the simulation centers of educational institutes. The leading causes of satisfaction were (1) authenticity of the VFTs, (2) easy-to-understand content, and (3) relevance to the job. The trainees suggested that Uzbek or Russian voice-overs would be better than subtitles in the video clip for focusing on VFT.

CONCLUSION

In situations where AFTs are not available, VFTs using edited videos and expert interviews are a good alternative to EMS education. Based on these results, it is possible that AFTs could be replaced by VFTs using qualified videos with designed instructions as a distance learning method under specific conditions.

Needs Assessment for the Development of Training Curricula for Internal Medicine Residents

BACKGROUND

Patient-centered outcomes can be achieved when common core and specialist competencies are achieved in a balanced manner. This study was conducted to assess the need to fill the gap between the defined competencies and learners' achievement, in order to improve the internal medicine (IM) training education curriculum for promoting patient-centered outcomes.

METHODS

A cross-sectional online survey was conducted. The participants were 202 IM specialists who obtained board certification in 2020-2021. We developed a questionnaire to investigate the self-evaluation of common core competencies and achievement level of IM essential competencies. For analysis, frequency tests, paired t-test, Borich priority formula, and χ² were performed.

RESULTS

In common core competencies, IM specialists recognized that their achievement levels in all competency categories were lower than their importance level (P < 0.001), and the highest educational demands were related to self-management. They assessed their five essential procedure skill levels as novice or advanced beginner status. The achievement level for the essential symptoms and signs that IM specialists should be able to manage was predominantly competent level. However, on average, 34.9% answered that they had never assessed during training for essential skills, and 29.7% answered the same for essential symptoms and signs.

CONCLUSION

We identified the priorities of core competencies, the level of achievement in essential procedures and patient care with essential symptoms and signs for IM training, and the related educational methods and assessment status. This study is expected to be used as basic data for developing and revising IM training educational curriculum.

Comparative effectiveness of JAK inhibitors and biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis

Background/Aims

We aimed to compare the effectiveness and safety of Janus kinase inhibitors (JAKi) vs. biologic disease- modifying antirheumatic drugs (bDMARD) in Korean patients with rheumatoid arthritis (RA) who had an inadequate response to conventional synthetic DMARDs.

Methods

A quasi-experimental, multi-center, prospective, non-randomized study was conducted to compare response rates between JAKi and bDMARDs in patients with RA naïve to targeted therapy. An interim analysis was performed to estimate the proportion of patients achieving low disease activity (LDA) based on disease activity score (DAS)-28- erythroid sedimentation rate (ESR) (DAS28-ESR) at 24 weeks after treatment initiation and to evaluate the development of adverse events (AEs).

Results

Among 506 patients enrolled from 17 institutions between April 2020 and August 2022, 346 (196 JAKi group and 150 bDMARD group) were included in the analysis. After 24 weeks of treatment, 49.0% of JAKi users and 48.7% of bDMARD users achieved LDA (p = 0.954). DAS28-ESR remission rates were also comparable between JAKi and bDMARD users (30.1% and 31.3%, respectively; p = 0.806). The frequency of AEs reported in the JAKi group was numerically higher than that in the bDMARDs group, but the frequencies of serious and severe AEs were comparable between the groups.

Conclusions

Our interim findings reveal JAKi have comparable effectiveness and safety to bDMARDs at 24 weeks after treatment initiation.

Transmembrane topology and oligomeric nature of an astrocytic membrane protein, MLC1

MLC1 is a membrane protein mainly expressed in astrocytes, and genetic mutations lead to the development of a leukodystrophy, megalencephalic leukoencephalopathy with subcortical cysts disease. Currently, the biochemical properties of the MLC1 protein are largely unknown. In this study, we aimed to characterize the transmembrane (TM) topology and oligomeric nature of the MLC1 protein. Systematic immunofluorescence staining data revealed that the MLC1 protein has eight TM domains and that both the N- and C-terminus face the cytoplasm. We found that MLC1 can be purified as an oligomer and could form a trimeric complex in both detergent micelles and reconstituted proteoliposomes. Additionally, a single-molecule photobleaching experiment showed that MLC1 protein complexes could consist of three MLC1 monomers in the reconstituted proteoliposomes. These results can provide a basis for both the high-resolution structural determination and functional characterization of the MLC1 protein.

Factors associated with time to diagnosis from symptom onset in patients with early rheumatoid arthritis

BACKGROUND/AIMS

To identify the factors associated with time to diagnosis after symptom onset in patients with early rheumatoid arthritis (RA).

METHODS

Early RA patients with ≤ 1 year of disease duration in the KORean Observational study Network for Arthritis (KORONA) database were included in this analysis. Patients were further divided into two groups according to the time to diagnosis from symptom onset: the early diagnosis group (time to diagnosis ≤ 1 year) and the late diagnosis group (time to diagnosis > 1 year). Using the multivariable regression model, we identified factors associated with early diagnosis.

RESULTS

Among 714 early RA patients, 401 patients (56.2%) and 313 patients (43.8%) were included in the early diagnosis and late diagnosis groups, respectively. The mean disease duration was 0.47 years in the early diagnosis group and 0.45 years in the late diagnosis group. In multivariable model analysis, greater age at onset (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02 to 1.05), high school education or higher (OR, 1.68; 95% CI, 1.14 to 2.47), higher income (OR, 1.48; 95% CI, 1.05 to 2.08), and initial small joint involvement (OR, 1.42; 95% CI, 1.02 to 1.98) were factors associated with early diagnosis. At diagnosis, disease activity scores using 28 joints on diagnosis (3.81 ± 1.44 vs. 3.82 ± 1.42, p = 0.92) and functional disability (0.65 ± 0.61 vs. 0.57 ± 0.62, p = 0.07) did not different between the two groups. However, hand joint erosion on X-ray (37.8% vs. 25.6%, p < 0.01) was more common in the late diagnosis group than the early diagnosis group.

CONCLUSION

Older onset age, higher educational level and income, and initial small joint involvement were positive factors for early diagnosis of RA.

Relationship between oxidative balance score and quality of life in patients with osteoarthritis: Data from the Korea National Health and Nutrition Examination Survey (2014-2015)

Osteoarthritis (OA) has a multifactorial etiology that includes oxidative stress. Oxidative balance score (OBS) is a well-known indicator of oxidative stress. However, the association between OBS and OA has not been assessed. Thus, this study aimed to investigate the associations of OBS with OA and quality of life (QOL) in patients with OA.By using data from the Korea National Health and Nutrition Examination Survey VI, patients previously diagnosed and/or treated by a physician were considered to have OA regardless of the affected joints. The control group was defined as participants without any form of chronic arthritis. OBS was calculated by combining 10 pro-oxidant and antioxidant factors through a baseline nutritional and lifestyle assessment. Higher OBS scores indicated a predominance of antioxidant exposure. Multivariable logistic regression was used to estimate the adjusted odds ratios (ORs) for OA, and the EuroQoL five-dimensional questionnaire (EQ5D) was used in patients with OA after adjusting for demographic factors and comorbidities.Among the 14,930 participants, 296 patients with OA, and 1,309 controls were included in the analysis. In the age- and sex-adjusted model, the OR of the total OBS for OA was significant. In the full model adjusted for age, sex, education, income, and comorbidities, the total OBS for OA was not significant. Only the non-dietary pro-oxidant OBS had a significant inverse association with OA. The patients with OA who had a high EQ5D score had a higher total OBS than those with a low EQ5D score. The OR of the total OBS for a high EQ5D score was 1.14 in the multivariable logistic regression model. As we analyzed the OBS as a categorical variable (reference = Q1), the ORs of the Q2, Q3, and Q4 (highest) total OBS were 1.43, 2.71, and 2.22, respectively.In the fully adjusted model, the total OBS was not associated with OA. However, a positive association was observed between the total OBS and QOL in the patients with OA, indicating that antioxidative status was associated with better QOL in patients with OA.

How do medical students actually think while solving problems in three different types of clinical assessments in Korea: Clinical performance examination (CPX), multimedia case-based assessment (CBA), and modified essay question (MEQ)

PURPOSE

This study aimed to explore students' cognitive patterns while solving clinical problems in three different types of assessments - clinical performance examination (CPX), multimedia case-based assessment (CBA), and modified essay question (MEQ) - and thus, to understand how different types of assessments can afford different thinking.

METHODS

A total of six test-performance cases from two fourth-year medical students were used for a cross-case study. Data were collected through one-on-one interviews using a stimulated recall protocol where students were: 1) shown videos of themselves taking each assessment and 2) asked to elaborate on what they were thinking. The unit of analysis was the smallest phrases or sentences, from the participants' narratives, representing a meaningful cognitive occurrence. The narrative data were reorganized chronologically and then analyzed according to a frame of hypothetico-deductive reasoning as clinical reasoning.

RESULTS

Both participants demonstrated similar patterns in their proportional frequencies of clinical reasoning on the same clinical assessment. The results also revealed that the three different assessment types may afford different aspects of clinical reasoning. For example, the CPX highly promoted the participants' reasoning related to inquiry strategy, while the MEQ highly promoted hypothesis generation. Similarly, the participants' data analysis and synthesis were more afforded by the CBA than the other types.

CONCLUSION

This study discovered that different assessment design affords different thinking in problem-solving. This finding can contribute to leveraging ways of improving current clinical assessments. Importantly, the research method used in this study can be utilized as an alternative way of examining the validity of clinical assessments.

Clinical outcomes of patients with active rheumatoid arthritis with normal acute phase reactant values

AIM

Despite high clinical disease activity, some patients with active rheumatoid arthritis (RA) have normal acute phase reactant (APR) values. This study aimed to determine the clinical outcomes of active RA patients with normal APR values.

METHOD

Of 5376 patients with RA enrolled in the Korean observational study network for arthritis (KORONA) registry, 400 patients with disease duration of <2 years who had Clinical Disease Activity Index (CDAI) score of >2.8 at baseline, biologic-naïve, and erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) drawn at both baseline and 2-year follow-up visits were identified. Patients were grouped according to baseline APR levels: normal APRs, one APR elevated, and both APRs elevated.

RESULTS

Baseline tender and swollen joint counts, mean CDAI and Health Assessment Questionnaire-Disability Index (HAQ-DI) scores were significantly lower in the normal APRs group compared with APR-elevated groups (P < 0.0001). At 2-year follow-up, mean CDAI scores, HAQ-DI, and percentage of the patient achieving remission were not significantly different between the normal APRs group compared with the APR-elevated groups regardless of the baseline disease activity. However, in patients with baseline CDAI moderate to high disease activity, the normal APRs group less frequently required initiation of the biologic disease-modifying anti-rheumatic drugs compared with the APR-elevated groups (P = 0.044).

CONCLUSION

Active RA patients with normal APR values have milder disease presentation, but similar clinical outcomes to those with elevated APRs.

Impact of early diagnosis on functional disability in rheumatoid arthritis

BACKGROUND/AIMS

To determine whether early diagnosis is beneficial for functional status of various disease durations in rheumatoid arthritis (RA) patients.

METHODS

A total of 4,540 RA patients were enrolled as part of the Korean Observational Study Network for Arthritis (KORONA). We defined early diagnosis as a lag time between symptom onset and RA diagnosis of ≤ 12 months, whereas patients with a longer lag time comprised the delayed diagnosis group. Demographic characteristics and outcomes were compared between early and delayed diagnosis groups. Logistic regression analyses were performed to identify the impact of early diagnosis on the development of functional disability in RA patients.

RESULTS

A total of 2,597 patients (57.2%) were included in the early diagnosis group. The average Health Assessment Questionnaire-Disability Index (HAQ-DI) score was higher in the delayed diagnosis group (0.64 ± 0.63 vs. 0.70 ± 0.66, p < 0.01), and the proportion of patients with no functional disability (HAQ = 0) was higher in the early diagnosis group (22.9% vs. 20.0%, p = 0.02). In multivariable analyses, early diagnosis was independently associated with no functional disability (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.01 to 1.40). In a subgroup analysis according to disease duration, early diagnosis was associated with no functional disability in patients with disease duration < 5 years (OR, 1.37; 95% CI, 1.09 to 1.72) but not in patients with longer disease duration (for 5 to 10 years: OR, 1.07; 95% CI, 0.75 to 1.52; for ≥ 10 years: OR, 0.92; 95% CI, 0.65 to 1.28).

CONCLUSIONS

Early diagnosis is associated with no functional disability, especially in patients with shorter disease duration.

Do medical students generate sound arguments during small group discussions in problem-based learning?: an analysis of preclinical medical students' argumentation according to a framework of hypothetico-deductive reasoning

PURPOSE

Hypothetico-deductive reasoning (HDR) is an essential learning activity and a learning outcome in problem-based learning (PBL). It is important for medical students to engage in the HDR process through argumentation during their small group discussions in PBL. This study aimed to analyze the quality of preclinical medical students' argumentation according to each phase of HDR in PBL.

METHODS

Participants were 15 first-year preclinical students divided into two small groups. A set of three 2-hour discussion sessions from each of the two groups during a 1-week-long PBL unit on the cardiovascular system was audio-recorded. The arguments constructed by the students were analyzed using a coding scheme, which included four types of argumentation (Type 0: incomplete, Type 1: claim only, Type 2: claim with data, and Type 3: claim with data and warrant). The mean frequency of each type of argumentation according to each HDR phase across the two small groups was calculated.

RESULTS

During small group discussions, Type 1 arguments were generated most often (frequency=120.5, 43%), whereas the least common were Type 3 arguments (frequency=24.5, 8.7%) among the four types of arguments.

CONCLUSION

The results of this study revealed that the students predominantly made claims without proper justifications; they often omitted data for supporting their claims or did not provide warrants to connect the claims and data. The findings suggest instructional interventions to enhance the quality of medical students' arguments in PBL, including promoting students' comprehension of the structure of argumentation for HDR processes and questioning.

Factors Contributing to Discordance between the 2011 ACR/EULAR Criteria and Physician Clinical Judgment for the Identification of Remission in Patients with Rheumatoid Arthritis

Remission is a primary end point of in clinical practice and trials of treatments for rheumatoid arthritis (RA). The 2011 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) remission criteria were developed to provide a consensus definition of remission. This study aimed to assess the concordance between the new remission criteria and the physician's clinical judgment of remission and also to identify factors that affect the discordance between these two approaches. A total of 3,209 patients with RA were included from the KORean Observational Study Network for Arthritis (KORONA) database. The frequency of remission was evaluated based on each approach. The agreement between the results was estimated by Cohen's kappa (κ). Patients with remission according to the 2011 ACR/EULAR criteria (i.e. the Boolean criteria) and/or physician judgment (n = 855) were divided into three groups: concordant remission, the Boolean criteria only, and physician judgment only. Multinomial logistic regression analysis was used to identify factors responsible for the assignment of patients with remission to one of the discordant groups rather than the concordant group. The remission rates using the Boolean criteria and physician judgment were 10.5% and 19.9%, respectively. The agreement between two approaches for remission was low (κ = 0.226) and the concordant remission rate was only 5.5% (n = 177). Pain affected classification in both discordant groups, whereas fatigue was associated with remission only by physician clinical judgment. The Boolean criteria were more stringent than clinical judgment. Patient subjective symptoms such as pain and fatigue were associated with discordance between the two approaches.

Using standardized patients versus video cases for representing clinical problems in problem-based learning

PURPOSE

The quality of problem representation is critical for developing students' problem-solving abilities in problem-based learning (PBL). This study investigates preclinical students' experience with standardized patients (SPs) as a problem representation method compared to using video cases in PBL.

METHODS

A cohort of 99 second-year preclinical students from Inje University College of Medicine (IUCM) responded to a Likert scale questionnaire on their learning experiences after they had experienced both video cases and SPs in PBL. The questionnaire consisted of 14 items with eight subcategories: problem identification, hypothesis generation, motivation, collaborative learning, reflective thinking, authenticity, patient-doctor communication, and attitude toward patients.

RESULTS

The results reveal that using SPs led to the preclinical students having significantly positive experiences in boosting patient-doctor communication skills; the perceived authenticity of their clinical situations; development of proper attitudes toward patients; and motivation, reflective thinking, and collaborative learning when compared to using video cases. The SPs also provided more challenges than the video cases during problem identification and hypotheses generation.

CONCLUSION

SPs are more effective than video cases in delivering higher levels of authenticity in clinical problems for PBL. The interaction with SPs engages preclinical students in deeper thinking and discussion; growth of communication skills; development of proper attitudes toward patients; and motivation. Considering the higher cost of SPs compared with video cases, SPs could be used most advantageously during the preclinical period in the IUCM curriculum.

What factors affect discordance between physicians and patients in the global assessment of disease activity in rheumatoid arthritis?

OBJECTIVE

To identify the level of agreement between patients with rheumatoid arthritis (RA) and physicians in the global assessment of disease activity and to explore factors influencing their discordance.

METHODS

A total of 4368 patients with RA were analyzed from the KORean Observational study Network for Arthritis (KORONA) database. Patients were divided into four subgroups according to difference from their physicians in the assessment of disease activity by substracting physician's visual analog scale (VAS) from patient's VAS as follows: positive discordance group I (10 mm ≤ discordance <25 mm), positive discordance group II (≥25 mm), concordance (<|10| mm), and negative discordance (≤ -10mm). Multinomial logistic regression analysis was performed to identify factors associated with discordance.

RESULTS

Only 1350 (29.2%) patients were classified in the concordance group. Positive discordance was found in 52.3% of the patients (n = 2425), with 33.7% (n = 1563) showing marked discordance (≥25 mm). The high disease activity (OR =1.41), gastrointestinal (GI) disease (OR =1.28), pain (OR =1.12), fatigue (OR =1.07) were consistently associated with positive discordance.

CONCLUSION

More than half of patients with RA thought their disease more severe than their physicians. In addition to high disease activity, pain, fatigue, and sleep disturbance or GI disease were associated with the discordance between physicians and patients with RA.

The frequency of and risk factors for osteoporosis in Korean patients with rheumatoid arthritis

BACKGROUND

The aim of this study was to investigate the prevalence of osteoporosis in rheumatoid arthritis (RA) patients and to analyze the risk factors in these patients using the KORean Observational study Network for Arthritis (KORONA) database.

METHODS

Among the RA patients in the KORONA who were recruited between July 2009 and December 2011, postmenopausal women with bone mineral density (BMD) results within one year from the time of KORONA enrollment were included in this study. The baseline characteristics of patients in three groups, defined by BMD results, were compared. The BMD measurement rates and prevalence of osteoporosis in the study patients were calculated in accordance with age and gender subgroups. Multivariable logistic regression analysis was used to explore the association between osteoporosis and demographics and disease-related risk factors.

RESULTS

Of 1322 postmenopausal woman patients with RA in whom BMD was measured within one year of study enrollment, 619 patients (46.8 %) were in the osteoporosis group (T-score ≤ -2.5 SD). RA patients with osteoporosis had a higher frequency of previous fractures than those in other groups, especially fractures of the femur (p = 0.004) and wrist (p = 0.042). Advanced age (≥70 years; OR = 2.28, 95 % CI: 1.40-3.58), lower body mass index (<25; OR = 2.14, 95 % CI:1.52-3.02), longer disease duration (≥10 years; OR = 1.46, 95 % CI: 1.07-2.00), higher cumulative glucocorticoid dose (OR = 1.03, 95 % CI: 1.01-1.05), and higher Health Assessment Questionnaire score (OR = 1.37, 95 % CI:1.11-1.69) were independent risk factors for osteoporosis.

CONCLUSION

A large percentage (90.8 %) of RA patients enrolled in the KORONA cohort had osteoporosis and osteopenia. Nevertheless, BMD measurement rates in this population remained low, despite high risk groups of fractures.

Factors Associated with the Use of Complementary and Alternative Medicine for Korean Patients with Rheumatoid Arthritis

Objective.

Rheumatoid arthritis (RA) is a chronic autoimmune disease that is often painful and debilitating. Patients with RA are increasingly receiving complementary and alternative medicine (CAM). We aimed to identify the patient characteristics and disease-specific factors associated with Korean patients with RA who decide to start treatment with CAM.

Methods.

Among the total 5371 patients with RA in the KORean Observational study Network for Arthritis (KORONA), 2175 patients who had no experience with CAM were included in our study. In our study, we assessed the frequency of new incident CAM use, its patterns, and the predictive factors of new CAM use.

Results.

Of the 2175 patients, 229 patients (10.5%) newly started receiving CAM within a year of enrolling in the cohort. Of those who started treatment with CAM, 17.0% received only herbal medicine, 54.6% only acupuncture treatments (7.0% used a combination of both), and 21.4% “Other” (e.g., physical therapy and placental extract injections). Women (OR 1.89, 95% CI 1.13–3.14) and patients with depression (OR 3.52, 95% CI 1.65–7.50) were significantly more likely to be treated with CAM. Regarding household types, patients who lived in an extended family (OR 1.78, 95% CI 1.08–2.95) or as part of a couple (OR 1.55, 95% CI 1.07–2.24) were more likely to be treated with CAM than patients living in a nuclear family.

Conclusion.

Our study found, within a year, an incidence rate of 10.5% for new CAM use among patients with no previous experience with CAM. Sex, depression, and household type were significantly associated with new CAM use.

Survival and prognostic factors in patients with connective tissue disease-associated pulmonary hypertension diagnosed by echocardiography: results from a Korean nationwide registry

OBJECTIVES

Pulmonary arterial hypertension (PAH) is a major cause of mortality in connective tissue disease (CTD). The survival rates and mortality-predictive factors of a nationwide registry of Korean patients with CTD-PH measured by echocardiography were determined.

METHODS

Patients with CTD-PH were enrolled between April 2008 and December 2012. Hemodynamic parameters and clinical data (WHO-functional class [FC], organ involvement, laboratory tests and treatment agents) were recorded. Survival rates were calculated by using the Kaplan-Meier method. Mortality-associated factors were examined by Cox proportional hazards regression analysis.

RESULTS

In total, 174 incident PH cases (61 with systemic lupus erythematosus, 50 with systemic sclerosis, 10 with mixed CTD, 22 with rheumatoid arthritis (RA) and 31 with other CTDs) were diagnosed by Doppler echocardiography. Of these, 25 (14%) died during the 3.8 ± 2.7 year follow-up period after PH diagnosis. The 1- and 3-year survival rates were 90.7% and 87.3%, respectively. Compared to the other CTD-PHs, RA-PH had the lowest survival rates (56% 3 year survival; P = 0.022). Multiple regression analysis revealed that low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were poor prognostic factors (P = 0.008, 0.04 and 0.009, respectively). Anti-UI-RNP (ribonucleoprotein) antibody positivity was protective (P = 0.022). In patients with WHO-FC III/IV, patients who received vasodilators had lower mortality than those who did not (P = 0.038).

CONCLUSIONS

In Korean patients with CTD-PH, the 3-year survival rate was 87%. Low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were independent poor prognostic factors. Anti-UI-RNP antibody was protective. Prompt PAH-specific vasodilator therapy may improve the survival of patients with severe CTD-PH.

Seasonality of gout in Korea: a multicenter study

The object of this study was to evaluate the seasonality of gout in Korea. We retrospectively examined data from 330 patients seen at nine rheumatology clinics, treated with urate lowering therapy (ULT) more than one year after stopping prophylactic medication. Demographic data, clinical and laboratory features, and seasonality of gout onset and flares were collected. Season was classified in three-month intervals. The mean age was 52.2 yr and mean disease duration was 26.8 months. The male to female count was 318:12. The onset of acute gouty attacks was obtained in 256 patients. Gout developed most commonly in summer season (36.7%) (P<0.001) and in June (15.6%, P=0.002). During ULT, there were 147 (male 97.3%) gout flares. Although there was no statistically significant difference, gout flares were more common in summer (30.6%). Aggravating factors were identified in 57 flares: alcohol (72.0%) was most common. In the patients who attained target serum uric acid (<6 mg/dL) at the end of prophylaxis, gout flares were high in fall (35.8%) and September (17.0%). In Korea, the summer is most common season of gout onset and there is a tendency for gout flares to increase during ULT in summer/fall season.

Poor agreement between QuantiFERON-TB Gold test and tuberculin skin test results for the diagnosis of latent tuberculosis infection in rheumatoid arthritis patients and healthy controls

BACKGROUND/AIMS

We investigated the agreement between the QuantiFERON-TB Gold (QFT-Gold) test and the tuberculin skin test (TST) in the diagnosis of latent tuberculosis infection in patients with rheumatoid arthritis (RA), compared with healthy controls, in Korea.

METHODS

We recruited 64 patients with RA and 79 healthy controls at two university hospitals in South Korea. The participants underwent both the QFT-Gold test and the TST simultaneously between August 2006 and February 2009. All patients were diagnosed using the classification criteria for RA revised in 1987 by the American College of Rheumatology. Bacillus Calmette-Guérin vaccination status and current medications were evaluated, and disease activities were assessed using the Disease Activity Score in 28 joints. Eleven patients with RA produced indeterminate QFT-Gold test results and were thus excluded from the kappa analysis.

RESULTS

Based on an induration of 10 mm in diameter as the TST cutoff value, the QFT-Gold test and TST demonstrated 75.0% agreement (κ = 0.23) in patients with RA and 75.9% agreement (κ = 0.19) in healthy controls. Among the 56 patients with RA who had negative TST results, 11 patients (17.2%) also yielded indeterminate QFT-Gold results.

CONCLUSIONS

Our study showed poor agreement between the results of the QFT-Gold test and the TST in both RA patients and healthy controls. Based on these findings, we emphasize the importance of making clinical decisions in the diagnosis of latent tuberculosis in Koreans with or without RA.

IL-17-deficient allogeneic bone marrow transplantation prevents the induction of collagen-induced arthritis in DBA/1J mice

IL-17-producing CD4+ T cells (Th17) play important functions in autoimmune diseases and allograft rejection of solid organs. We examined the effects of IL 17 and its mechanism of action on arthritis in a murine collagen-induced arthritis (CIA) model using bone marrow transplantation (BMT) system. DBA/1J mice were administered a lethal radiation dose and then rescued with bone marrow derived from either wild-type (WT) or IL-17-/- mice on C57BL/6 background mice. CIA was induced after the bone marrow transplant, and disease progression was characterized. DBA/1J mice with CIA that received IL-17-/- donor bone marrow showed potently inhibited development and severity of clinical arthritis as compared with CIA mice that received WT bone marrow. Reduced secretion of the pro-inflammatory cytokines tumor necrosis factor-α, IL-1β, and IL-6, and collagen-specific T cell responses were observed in mice that received IL-17-/- bone marrow. IL-17 blockade also inhibited effector T cell proliferation by reciprocally regulating the Treg/Th17 ratio. IL-17 blockade prevented joint destruction in mice with CIA. These findings suggest that CIA with BMT is a viable method of immunological manipulation and that IL-17 deficiency suppresses severe joint destruction and inflammation in CIA mice. There may be clinical benefits in blocking IL-17 and BMT in the treatment of rheumatoid arthritis.

Do patients with elderly-onset rheumatoid arthritis have severe functional disability?

OBJECTIVE

To identify the clinical features of elderly-onset rheumatoid arthritis (EORA) and their impact on disease outcome.

METHODS

A total of 3169 rheumatoid arthritis (RA) patients were recruited as part of the Korean Observational Study Network for Arthritis, the nationwide cohort of South Korea. Patients were stratified according to age at disease onset: <40 years (younger age-onset RA, n = 1167), between the ages of 40 and 59 (middle-aged-onset RA, n = 1516), and ≥60 years (EORA, n = 486). To evaluate the significance of differences in clinical features among these 3 groups, we performed analysis of variance (anova) and the χ(2) test. We used multivariable logistic regression analysis to examine the association of onset age with functional disability measured with Health Assessment Questionnaire-Disability Index (HAQDI).

RESULTS

EORA patients were associated with high HAQDI (≥1) in bivariable analysis [odds ratio (OR) 1.36, confidence interval (CI) 1.04-1.77]. However, in multivariable analysis, not elderly onset but patients' age, female gender, high disease activity, disease duration over 10 years, and comorbidity with cardiovascular disease were associated with high HAQDI. Only in a predefined subgroup with disease duration <10 years, elderly onset was an independent influencing factor for the functional disability of RA patients (OR 3.04, CI 1.85-5.67: disease duration of <5 years, OR 3.07, CI 1.64-5.74: disease duration of 5 to 10 years).

CONCLUSIONS

Disease onset in older age was associated independently with functional disability of RA patients who have relatively short disease duration.

Korean Observational Study Network for Arthritis (KORONA): establishment of a prospective multicenter cohort for rheumatoid arthritis in South Korea

OBJECTIVES

The object of this study was to introduce the KORean Observational study Network for Arthritis (KORONA) registry with an emphasis on the design of the Korean rheumatoid arthritis (RA) national database, as well as to provide an overview of the RA patients who are currently registered in KORONA.

METHODS

The KORONA was established in July 2009 by the Clinical Research Center for Rheumatoid Arthritis (CRCRA) in South Korea. KORONA is based on a prospective protocol and standard, defined data collection instruments. Demographic and clinical features, laboratory and radiologic data, health-related outcomes, treatment side effects, resource utilization, and health behaviors of the RA cohort patients are recorded in a database.

RESULTS

A total of 23 institutions, which are about 38% of the rheumatologic departments at tertiary academic hospitals across South Korea, are part of KORONA. The quality control of data collection and management has been performed through annual monitoring and auditing, staff training, and providing standard operation protocol by the executive committee of CRCRA. As of 31 December 2010, 4721 patients with established RA were included in KORONA, because an annual survey had started to be performed in July 2010.

CONCLUSIONS

KORONA is the first nationwide Korean RA-specific cohort and it will provide valuable "real-world" information for Korean RA patients.

Regulation of B cell activating factor (BAFF) receptor expression by NF-ΚB signaling in rheumatoid arthritis B cells

B cells play an important role in the pathogenesis of rheumatoid arthritis (RA). High levels of B cell activating factor (BAFF) are detected in autoimmune diseases. BAFF and BAFF receptor (BAFF-R) are expressed in B and T cells of RA synovium. The study was undertaken to identify the NF-ΚB signal pathway involved in the induction of BAFF-R in human B cells. Immunohistochemical staining of NF-ΚB p65, NF-ΚB p50, BAFF, and BAFF-R was performed on sections of synovium from severe and mild RA and osteoarthritis (OA) patients. Peripheral blood mononuclear cells (PBMCs) were isolated from control and RA patients and B cells were isolated from controls. BAFF-R was analyzed by flow cytometry, realtime PCR and confocal staining after treatment with NF-ΚB inhibitors. NF-ΚB p65, NF-ΚB p50, BAFF, and BAFF-R were highly expressed in severe RA synovium relative to mild RA synovium or OA synovium. BAFF-R expression was reduced by NF-ΚB inhibitors in PBMCs and B cells from normal controls. We also showed reduction in expression of BAFF-R via inhibition of the NF-ΚB pathway in PBMCs of RA patients. BAFF/BAFF-R signaling is an important mechanism of pathogenesis in RA and that BAFF-R reduction by NF-ΚB blocking therapy is another choice for controlling B cells in autoimmune diseases such as RA.

Development of a coronary aneurysm at a sirolimus-eluting stent-implanted lesion in a patient with churg-strauss syndrome

A coronary aneurysm (CA) can occur in sirolimus-eluting stent (SES)-implanted coronary lesions. Although several possible mechanisms have been suggested, the precise pathogenesis of a CA in SES-implanted lesions is still unknown. We report a patient with Churg-Strauss syndrome who underwent successful percutaneous coronary intervention with SES and then experienced a CA in an SES-implanted coronary lesion. We describe the CA characteristics through the use of coronary angiography, coronary 64-multidetector computed tomography, and intravascular ultrasound and discuss the etiological factors for the CA in this patient.

A nationwide seroprevalence of total antibody to hepatitis A virus from 2005 to 2009: age and area-adjusted prevalence rates

Background/Aims

Recent outbreak of hepatitis A in Korea is clearly related to the epidemiological shift of hepatitis A virus (HAV). However, nationwide seroprevalence data have been limited. This study estimated the nationwide, age- and area-adjusted anti-HAV prevalence from 2005 to 2009.

Methods

Retrospective analysis of the results of total anti-HAV test in 25,140 cases which were requested by 1,699 medical institutions throughout the nation to Seoul Clinical Laboratory from Jan. 1 2005 to Dec. 31 2009 was performed. The estimated seroprevalence was adjusted by area and age of the standard population based on the 2005 Census data from Korea National Statistical Office.

Results

The area-adjusted anti-HAV prevalence in the children younger than 10 years were 33.4% in 2005 and 69.9% in 2009. The most susceptible age groups to HAV infection during the last 5 years were teenagers and the young adults in their age of twenties. The area-adjusted seroprevalence in 2009 were 11.9% in the age group of 20-29 years, 23.4% in the age group of 10-19 years, 48.4% in the age group of 30-39 years. The population in 40-49 years showed geographically different seroprevalence with the lowest rate in Seoul (80%).

Conclusions

The most susceptible age group to HAV infection is 10-29 years, while the young children less than 10 years showed about 70% seropositivity. The changing seroepidemiology should be monitored continuously for the proper vaccination and patient care.

Histiocytic necrotizing lymphadenitis in the context of systemic lupus erythematosus (SLE): Is histiocytic necrotizing lymphadenitis in SLE associated with skin lesions?

Histiocytic necrotizing lymphadenitis (HNL), or Kikuchi's disease, is a benign and self-limiting lymphadenopathy that typically affects young Asian females. It presents with lymphadenopathy, usually cervical, accompanied by fever, chills and leukopenia. Although the association between systemic lupus erythematosus (SLE) and HNL is rare, the number of reports of HNL in SLE patients is increasing. We present nine cases of HNL in patients with SLE. Among the seven patients with diverse skin manifestations, three had skin manifestations that were histologically compatible with SLE. A review of previous reports in the literature showed that cutaneous involvement was commonly found in HNL in association with SLE. In the patients who had simultaneous onset of both diseases, lupus flare-ups were commonly observed. We suggest that HNL in SLE patients is associated with cutaneous manifestations. This report contributes to our understanding of the relationship between these diseases.

NF-κB inhibition leads to increased synthesis and secretion of MIF in human CD4+T cells (48.2)

To examine the effects of NF-κB inhibition on the secretion of macrophage migration inhibitory factor (MIF) in CD4+ T cells. Isolated human CD4+ T cells were cultured with NF-κB inhibitors for 24 hrs. MIF levels were evaluated by intracellular FACs, ELISA, and real time PCR. The levels of intracellular O2-, H2O2, and glutathione were evaluated by intracellular FACs. The amounts of phosphorylated Akt and c-Jun were measured by Western blotting. Treatment of CD4+ T cells with NF-κB inhibitors resulted in a significant increase of MIF concentration in culture supernatants, MIF gene expression and O2- production and decrease of intracellular MIF, H2O2, and GSH. Treatment with LY294002, and SP600125 suppressed NF-κB inhibitors induced MIF mRNA expression and MIF secretion and inhibited parthenolide induced phosphorylation of Akt and c-Jun. Treatment with H2O2 also decreased the amounts of intracellular MIF protein and increased MIF level in the culture supernatant. NAC, an antioxidant precursor of GSH, inhibited parthenolide or H2O2 induced secretion of MIF. These results indicate inhibition of NF-κB leads to release of MIF through de novo synthesis of MIF and secretion of preformed MIF in CD4+ T cells through reactive oxygen species production. .

Validation of the classification criteria commonly used in Korea and a modified set of preliminary criteria for Behçet's disease: a multi-center study

OBJECTIVE

Recently we have proposed a modified set of criteria to settle the questions raised regarding the International Study Group (ISG) criteria for Behçet's disease (BD). The aim of the present study was to validate the two pre-existing criteria sets commonly used in Korea, the ISG criteria and the criteria of the Behçet's Disease Research Committee of Japan (Japanese criteria), as well as the proposed modified criteria.

METHODS

The study population included 155 consecutive patients with BD and 170 controls with non-Behçet's rheumatic diseases. Detailed data for all of the subjects were recorded prospectively by the participating physicians on a standard form that listed the clinical features of BD. The sensitivity, specificity, and accuracy of each set of the criteria were measured.

RESULTS

Of the three criteria sets employed, the modified criteria were the most accurate, with an accuracy of 96.3%. The ISG criteria often failed to classify the following patients with BD: patients with only oral and genital ulcerations, certain patients with intestinal ulcerations, patients who did not manifest oral ulcerations, and patients with acute disease but fewer than three recurrent oral ulceration relapses in a 1-year period. The Japanese criteria also failed to categorize the following patients with BD: patients with oral and genital ulcerations, and patients with oral ulcerations, skin lesions, and a positive pathergy reaction. In addition, the Japanese criteria misclassified some of the control subjects with non-Behçet's uveitis as having BD.

CONCLUSIONS

The results of this study suggest that there are some points that need to be reconsidered in the clinical application of the two pre-existing sets of criteria. Although the modified criteria were the most accurate, further validation studies will be required in other ethnic populations.

The prevalence of atopy and atopic diseases in Behçet's disease

OBJECTIVE

The prevalence of Th-2 cell-mediated diseases, such as atopic diseases, has been noted to be low in Th-1 cell-mediated diseases. This study was undertaken to assess the prevalence of atopy and atopic diseases in Behçet's disease (BD), a Th-1 cell-mediated disease, and to investigate the clinical association between the atopy and the development of severe manifestations in BD.

METHODS

We examined 70 consecutive BD patients and 113 controls without BD or other inflammatory rheumatic diseases. The cumulative history of severe manifestations in BD patients was investigated during the disease course. A skin prick test was performed in all the subjects, and atopy was defined as present when the size of one or more allergen-induced wheals was equal to or larger than that caused by histamine. Atopic diseases were defined as present when there were relevant responses for atopic diseases on the questionnaires in the subjects with atopy. In addition, serum IgE levels and peripheral blood eosinophil counts were measured.

RESULTS

The prevalence of atopy and atopic diseases was significantly lower in BD patients than in controls. Other atopy parameters, such as serum IgE levels and peripheral blood eosinophil counts, were also significantly lower in BD patients when compared with controls. However, atopy, serum IgE levels, and peripheral blood eosinophil counts did not differ significantly between BD patients with and without severe manifestations.

CONCLUSION

The prevalence of Th-2 cell-mediated conditions, such as atopy and atopic diseases, appeared to be lower in BD, a Th-1 cell-mediated disease. In addition, a Th-1 and Th-2 balance may not influence the development of severe manifestations in BD.

Evidence for the essential histidine residues in geranylgeranyl transferase type I from bovine testis

Geranylgeranyl transferase was purified 30,000-fold by sequential use of 30-50% ammonium sulfate fractionation, Q-Sepharose anion exchange chromatography, Phenyl Superose hydrophobic interaction chromatography, Sephacryl S-300 gel filtration chromatography, and peptide (YREKKFFCAIL) affinity chromatography. Geranylgeranyl transferase, when incubated with diethyl pyrocarbonate (DEPC), a histidine-specific reagent, shows time-dependent inactivation, and the activity is restored by the addition of neutral hydroxylamine. The inactivation follows pseudo-first order kinetics with a second order rate constant of 0.319 M-1min-1. The overall results thus provide evidence that a histidine residue in the active site is involved in the catalytic mechanism of the geranylgeranyl transferase reaction.