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Prolongation of the QT interval by antiarrhythmic drugs is the primary cause of torsade de pointes. Although there are previous reports of drug-induced torsade de pointes in patients undergoing hemodialysis, torsade de pointes caused by a sudden decrease of potassium levels in patients initiating hemodialysis has not been well described. A 70-year-old woman with recurrent bilateral gluteal abscesses visited the hospital for antibiotic treatment. Twenty-eight days after admission, atrial fibrillation with rapid ventricular rhythm was newly detected and was controlled with intravenous amiodarone treatment. After developing pulmonary edema that did not improve with diuretic treatment, she underwent emergency hemodialysis. During hemodialysis, serum potassium and magnesium levels decreased to 3.1 and 1.7 mg/dL, respectively. The electrocardiogram showed torsade de pointes. Amiodarone treatment was stopped, and magnesium sulfate was infused. A higher concentration of potassium dialysate was used in continuous renal replacement therapy. Torsade de pointes episodes halted, and QT interval prolongation normalized. We describe a case with a rare complication of torsade de pointes upon initiating hemodialysis in a patient with QT prolongation. When initiating hemodialysis, serum potassium levels as well as electrocardiograms should be monitored in patients with a prolonged QT interval.

Background/Aims To analyze clinical characteristics of interstitial lung disease (ILD) associated with rheumatoid arthritis (RA), especially in patients with poor prognosis. Methods Seventy-seven RA patients with ILD and 231 age, sex, and disease duration-matched RA patients without ILD were enrolled in this retrospective study. Epidemiologic, clinical, and laboratory information were obtained through a medical chart review. Logistic regression analysis was used to estimate the risk of mortality in RA patients with ILD. Results Compared to the RA without ILD group, the RA with ILD group had significantly higher titers of rheumatoid factor and the anti-cyclic citrullinated peptide (p = 0.001 for both), higher levels of C-reactive protein (CRP) at the time of RA diagnosis (p = 0.014), and a higher erythrocyte sedimentation rate (p = 0.022) and CRP levels (p < 0.001) throughout the 10-year follow-up period. These patients also received a higher mean daily dose of corticosteroids (p < 0.001). In the subgroup analysis of RA patients with ILD, 28 patients (36.4%) died during follow-up. Multivariate analysis revealed that older age at the time of ILD diagnosis was significantly associated with mortality. Usual interstitial pneumonia (UIP) subtype on high-resolution computed tomography (HRCT) was also suggested as a poor prognostic factor. Conclusions The survival of RA patients with ILD is adversely affected by age at the time of ILD diagnosis. RA-ILD patients diagnosed after age 65 or with a UIP subtype on HRCT may have a poor prognosis.

Background To compare the outcomes of gastric, colon, lung, and breast cancer patients with and without rheumatic diseases (RD). Methods This retrospective study compared the cancer survival rates of a cohort of 122 cancer patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), dermatomyositis/polymyositis (DM/PM), or systemic sclerosis with that of a cohort of 366 age-, sex-, and, cancer type-matched patients without RD who received medical care from 2000 to 2014. Staging, comorbidities, and functional status were ascertained. Survival was compared using the Kaplan-Meier method. Relative risk of death was estimated as a hazard ratio (HR) using Cox regression analysis. Results The mean age of the RD patients at the time of cancer diagnosis was 58.7 ± 11.5 years. The overall survival rate of gastric cancer patients did not differ between the cohorts. The survival of lung or breast cancer was worse in patients with RA or DM/PM than in those without RD (all, p

This research involved 226 Jeonbuk Province school dietitians as subjects to investigate intake and perceptions of the healthy functional foods. Sixty nine percent of the school dietitians didn`t even know about the law enforcement concerning the health functional foods. Although 68.1% of the respondents said that they slightly knew about health functional foods, only 25% knew exactly what it was. As shown in the survey, most didn`t have the cognitive understanding did not understand which should be obtained by education. Sixty two percent of the answerers said they had experience of taking health various functional food products of various kinds such as supplements (57.9%), red ginseng products (52.9%), and chlorella products (30.0%). The motive of intake was in the order of fatigue restoration (25.7%), sickness prevention (22.9%), and nutrient replenishment (22.9%). A fascinating fact from this study was that the reason for healthy functional product intake was different between groups that was primarily interested in the products and those that was not. For those who had interest, the reason for intake was for sickness prevention. On the other hand, for those who didn`t have any interest, the reasons was primarily for fatigue restoration and they were mostly persuaded by close friends and relatives. Main concerns were in the order of side effects (4.72), efficacy after intake (4.59), cleanliness (4.51), reliability of the company (4.29), and price (4.23). In view of the study, it is clear that a lot of people are showing interest in healthy functional food products. However, dietitians who are experts in food and nutrition lacked knowledge and information on healthy functional food.

Introduction Rheumatic diseases (RDs) are associated with different cancers; however, it is unclear whether particular cancers are more prevalent in certain RDs. In the present study, we examined the relative incidence of several cancers in a single homogeneous cohort of patients with different RDs. Methods Patients (N = 3,586) diagnosed with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc), dermatomyositis (DM) or polymyositis were included. Cancer diagnosis was based on histopathology. The 2008 Korean National Cancer Registry served as the reference for calculating standardized incidence ratios (SIRs). Results During the follow-up period of 31,064 person-years, 187 patients developed cancer. RA and SLE patients showed an increased risk of non-Hodgkin’s lymphoma (SIR for RA patients = 3.387, 95% confidence interval (CI) = 1.462 to 6.673; SIR for SLE patients = 7.408, 95% CI = 2.405 to 17.287). SLE patients also had a higher risk of cervical cancer (SIR = 4.282, 95% CI = 1.722 to 8.824). SSc patients showed a higher risk of lung cancer (SIR = 4.917, 95% CI = 1.977 to 10.131). Endometrial cancer was increased only in patients with DM (SIR = 30.529, 95% CI = 3.697 to 110.283). RA patients had a lower risk for gastric cancer (SIR = 0.663, 95% CI = 0.327 to 0.998). The mean time between the RD and cancer diagnoses ranged from 0.1 to 16.6 years, with the shortest time observed in patients with DM (2.0 ± 2.1 years). Conclusions Different RDs are associated with particular cancers. Thus, cancer surveillance tailored to specific RDs might be beneficial. Electronic supplementary material The online version of this article (doi:10.1186/s13075-014-0428-x) contains supplementary material, which is available to authorized users.

Clinical characteristics of antitumor necrosis factor (TNF) agents-related tuberculosis (TB) in ankylosing spondylitis (AS) are not well described. The aim was to compare the incidences and the characteristics of TB in AS and rheumatoid arthritis (RA) during TNF inhibitor treatment. AS (n = 1,322) and RA (n = 3,154) patients who received medical care between January 2001 and August 2011 were enrolled. The incidence of TB in patients treated, or not, with TNF inhibitors and the clinical features associated with TB were explored. Seven patients with AS and seven with RA developed TB while receiving TNF inhibitor therapy, resulting in an incidence rate of 600.2/100,000 person-years (PYs) (95 % confidence interval (CI), 241.3–1236.3) for those with AS and 771.6/100,000 PYs (95 % CI, 310.2–1589.9) for those with RA. Incidence rate ratios for TNF inhibitor-treated vs. untreated patients were 4.87 for AS (95 % CI, 1.50–15.39; p

Autoinflammatory disease (AID) is a newly proposed category of disorders characterized by unprovoked episodes of inflammation without any infectious or autoimmune evidence. We aimed to characterize the clinical and genetic features of patients who had recurrent fever and multi-system inflammation but remain unclassified for any established AIDs. Medical records of 1,777 patients who visited our Rheumatology Clinic between March 2009 and December 2010 were reviewed to identify those who met the following criteria; 1) presence of fever, 2) inflammation in two or more organ systems, 3) recurrent nature of fever or inflammation, 4) no evidence of infection or malignancy, 5) absence of high titer autoantibodies, and 6) failure to satisfy any classification criteria for known AIDs. Genotyping was performed for common missense variants in MEFV, NOD2/CARD15, and TNFRSF1A. A small number of patients (17/1,777, 0.95%) were identified to meet the above criteria. Muco-cutaneous and musculoskeletal features were most common, but there was a considerable heterogeneity in symptom combination. Although they did not satisfy any established classification criteria for AIDs, substantial overlap was observed between the clinical spectrum of these patients and known AIDs. According to the newly proposed Eurofever criteria for periodic fevers, eleven of them were classified as TNF receptor-associated periodic syndrome and two as mevalonate kinase deficiency. However, no examined genetic variants including those in TNFRSF1A were found in these patients. A new set of classification criteria needs to be developed and validated for Asian patients with unclassified AIDs., Graphical Abstract

Background Diacerein is a drug used in osteoarthritis (OA) that elicits an inhibitory effect on interleukin-1 and metalloproteases. Although diacerein has shown modest efficacy and safety in the treatment of knee and hip OA, there have been no placebo-controlled clinical trials for hand OA. Objective The aim of the current study was to investigate the efficacy and tolerability of diacerein in patients with hand OA. Methods Patients fulfilling the American College of Rheumatology criteria for hand OA participated in this randomized, double-blind, placebo-controlled study. Eligible patients were >40 years of age, had at least 1 tender joint, and had a joint pain visual analog scale of >30 mm. Patients received diacerein (50 mg) or placebo BID for 12 weeks. The primary end point was the Australian/Canadian Osteoarthritis Hand Index (AUSCAN) pain score at 4 weeks. Secondary end points were AUSCAN pain score at 12 weeks and AUSCAN physical function and stiffness score, patient and physician global assessment, functional index of hand OA scores, and multidimensional health assessment questionnaire results at 4 weeks and 12 weeks. Results Eighty-six Korean patients were enrolled (42 diacerein, 44 placebo). The intention-to-treat and per-protocol analyses revealed no significant differences between the 2 groups in terms of change in AUSCAN pain score at 4 weeks, except for improvement in physician global assessment at 4 weeks (per-protocol analysis, P = 0.004). The safety profile of diacerein was comparable to placebo, except for frequent discoloration of the urine (88% vs 20%). Conclusion These results suggest that diacerein 50 mg BID may be ineffective in controlling the symptoms of hand OA. ClinicalTrials.gov identifier: NCT00685542.

Background The clinical importance of rheumatoid arthritis-associated interstitial lung disease has been increased because the usual interstitial pneumonia (UIP) is the most common subtype of interstitial lung disease (ILD) on high-resolution computed tomography (HRCT) in rheumatoid arthritis (RA)and has poor survival rate compared to other forms of ILD related to connective tissue disease. Objectives The clinical characteristics and laboratory data of RA patients with and without ILD were compared in order to clarify the risk factors for ILD in RA patients. Furthermore, risk factors of mortality in the RA patients with ILD group were analyzed. Methods A total of 77 RA patients with ILD and 231 age/sex-, and disease duration-matched RA patients without ILD who were followed from 1991 to 2011 at Seoul National University Hospital were enrolled in this study. Epidemiologic, clinical, and laboratory information including rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) were obtained through medical chart review. The erythrocyte sedimentation rates (ESR), C-reactive protein (CRP) levels, presence of erosion on joint X-rays, and mean corticosteroid doses were examined in order to compare RA outcomes between the RA patients with and without ILD. Cox proportional hazard models were used to estimate the risk of mortality in the RA patients with ILD. Results In the RA with ILD group, the titers of the RF and the anti-CCP were significantly higher compared with those in the RA without ILD group (p=0.001 for both). The RA patients with ILD had higher frequency of a history of tuberculosis or nontuberculous mycobacteria (NTM) (p=0.022). In addition, the RA with ILD group exhibited higher levels of CRP at the time of RA diagnosis (p=0.014) and higher ESR (p=0.022) and CRP levels (p Conclusions The RA patients with ILD had higher RF and anti-CCP titers and baseline CRP levels compared with those without ILD. A UIP subtype on HRCT and older age at the time of the diagnosis of ILD were significantly associated with mortality of RA with ILD. Disclosure of Interest None declared

Background Red blood cell distribution width (RDW) is a biomarker quantifying the variability of red blood cell size (anisocytosis) in the peripheral blood. High RDW is associated with inflammatory burden and it has been suggested as a potential marker for cardiovascular prognosis, mortality, or reflecting renal function in the various clinical conditions 1 . A recent study found the significant association between serum uric acid level and RDW in patients with untreated essential hypertension 2 . Gouty arthritis is an acute and severe inflammatory arthritis attributable to hyperuricemia, and closely associated with renal dysfunction and cardiovascular diseases. However, few studies have yet investigated the clinical significance of RDW in patients with gout. Objectives The aim of this study was to investigate the potential association of RDW value with clinical features in patients presenting with acute gout attack. Methods The medical records of patients who visited emergency room of Seoul National University Bundang Hospital for acute gout attack, from March 2003 to April 2014, were retrospectively reviewed. Cases were stratified into three groups according to the RDW tertiles ( 13.4%) and clinically relevant differences were evaluated by the ANOVA test or the chi-square test. The Pearson9s correlation approach was used to analyze the correlation between two continuous variables. To identify significant determinants influencing RDW, we used multiple linear regression analysis. Results Two-hundred and thirty-six patients with acute gout attack were included. The mean age was 49.38±16.85 years and the male ratio was 92.3% (n=218). The patients in the highest RDW tertile tended to be older, had higher levels of hemoglobin and lower levels of albumin, and had more recurrence of gout attack and renal impairment. RDW showed significant weak positive correlation with age (γ=0.224, p =0.001) and creatinine level (γ=0.237, p p p p =0.009) (Table 1). Conclusions Our data shows that high RDW in acute gout attack is related to the recurrence of gout attack and coexistence of chronic kidney disease. In acute gout attack, RDW, an easy and quick measurable index, may represent renal dysfunction rather than inflammatory burden or uric acid level, and physicians who treat acute gouty arthritis with high RDW should pay attention to the recurrence of gout attack and treatment. References Lippi G, Targher G, Montagnana M, Salvagno GL, Zoppini G, Guidi GC. Relation between red blood cell distribution width and inflammatory biomarkers in a large cohort of unselected outpatients. Arch Pathol Lab Med 2009;133:628-32. Luo M, Li ZZ, Li YY, Chen LZ, Yan SP, Chen P, et al. Relationship between red cell distribution width and serum uric acid in patients with untreated essential hypertension. Sci Rep 2014;4:7291. DOI: 10.1038/srep07291 Disclosure of Interest None declared

Felty syndrome (FS) is a rare manifestation in rheumatoid arthritis (RA) characterized by neutropenia and splenomegaly. Treatment for FS is not well established because there has been no randomized controlled study. A few recent reports found rituximab effective in patients with refractory FS. According to those reports, most patients with RA and FS had active arthritis. Here we report a case of a patient with glucocorticoid dependent and disease-modifying anti-rheumatic drugs (DMARDs) refractory FS and quiescent RA who was successfully treated with rituximab.

Relapsing polychondritis is an episodic, systemic inflammation of the cartilage with unknown autoimmune etiology. It leads to the destruction of cartilaginous structures of the ear, eye, nose, respiratory tract, joints, skin, and heart valve, and its presented symptoms are diverse. It can be improved mainly by corticosteroid or immunosuppressive agents. Recently, the use of biologic agents (TNF inhibitors, rituximab, tocilizumab et al) was reported from abroad. However, there is no reported case of relapsing polychondritis, which is treated by biologic agents in Korea. We report this first case of refractory relapsing polychondritis, which was improved with a treatment of Infliximab.

Background Patients with rheumatic diseases (RD) have underlying immune dysregulation and receive long-term immunosuppressive mediations which might negatively affect the outcome of a cancer in those patients. Conversely, autoimmune cells might help eliminate the cancer cells with a better outcome in RD patients. Objectives This study was aimed at systematically investigating effects of RD on the long term outcome of four most common cancers in a retrospective cohort study. Methods A total of 167 patients with RD and cancer and 501 age-, sex-, and cancer-matched controls without RD (1:3 ratio)who received their medical care at Seoul National University Hospital from 1992 to 2012 were included in this study. Survival curves were generated using the Kaplan-Meier plots and compared using log-ranks tests. Results The mean age of patients with RD was 57.2±11.5 years old. Female was dominant (75.0%). Rheumatoid arthritis was most common with 114 (68.4%) cases, followed by dermatomyositis/polymyositis (10.8%), systemic lupus erythematosus (10.8%), systemic sclerosis (10.2%). There were 42 (25.1%) gastric, 28 (16.8%) colon, 49 (29.3%) lung, and 48 (28.7%) breast cancers. One patient had 2 cancers. There was no significant difference in 5-year (90.0 % vs. 91.2%) and 10-year survival rates (84.3% vs. 85.0%, P=0.983) between the cancer patients with RD and the controls (Figure 1). In a subgroup analysis by cancer types, 5-year (100% vs. 92.2%) and 10-year cancer survival of gastric cancer were significantly better in the RD group as compared to the control group (100%, vs. 82.8%, P=0.026), whereas those of colon, lung, and breast cancer did not differ between them. Image/graph Conclusions This study clearly demonstrates that the cancer survival was not worse in patients with rheumatic diseases despite the additional presence of underlying defective immune system and concurrent use of immunosuppressive medications. Disclosure of Interest None Declared

Background Ankylosing spondylitis (AS) is a rheumatologic disease for which anti-TNF agents are effective. Tuberculosis (TBc) is one of the serious infectious complications of anti-TNF agents. However, clinical characteristics of anti-TNF agents-related TBc in AS are not well described. Objectives To investigate the clinical characteristics of active TBc which develops in AS patients after taking anti-TNF agents. Methods We enrolled all the patients with AS or rheumatoid arthritis (RA) who took anti-TNF agents at Seoul National University Hospital between Jan 2001 and Aug 2011. Medical records were reviewed for all the patients. TBc was defined as presence of M. tuberculosis in culture or typical radiographic findings and clinical response to anti-TBc medication. Clinical characteristics of AS patients who developed TBc were compared with those of RA. Results Median follow-up duration (range) were 30.7 (1.9∼48.9) months for AS and 19.6 (8.6∼47.2) months for RA. Conclusions When anti-TNF agents are prescribed in AS, TBc can develop as frequently as in RA. TBc developed later in AS than in RA after initiation of anti-TNF agents. Extrapulmonary tuberculosis was prevalent as in RA. Current prophylaxis method does not seem to adequately prevent tuberculosis in AS. Disclosure of Interest None Declared

Correspondence to Eun Young Lee, M.D., Ph.D. Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea Tel: +82-2-2072-0852, Fax: +82-2-762-9662, E-mail: elee@snu.ac.kr Copyrightc 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 피부근염에 동반된 혈전혈소판감소자색반병에서 리툭시맙 치료 1예

Objective. To assess the efficacy and safety of rituximab (RTX) on disease activity and muscle strength in patients with inflammatory myopathies refractory to conventional therapy. Methods. Four inflammatory myopathy patients who had been refractory to glucocorticoids, one or more immunosuppressive therapies and intravenous immunoglobulin were treated on an open-label basis. Each patient received two 500 mg doses of RTX 2 weeks apart in one cycle. In one patient who did not respond after the first cycle of RTX, the infusion schedule was modified by the physician. We measured muscle enzyme including CPK, LDH and assessed muscle strength individually to evaluate RTX response. Additionally anti-CD19 antibody was measured. Results. Three patients responded to the first cycle of RTX treatment with improvements in muscle enzyme and muscle strength, and then maintained physical function over the duration of several infusion cycles. In one patient, muscle enzyme did not decrease after the first cycle of RTX, and a high dose glucocorticoid was given. After modifying the treatment schedule with monthly RTX infusion, his muscle enzyme level and muscle strength improved. Anti-CD19 antibody decreased after RTX generally, but responses were variable. Herpes zoster infection occurred in two patients. Conclusion. Rituximab may be a therapeutic choice in refractory inflammatory myopathy. However a further trial is needed to confirm the efficacy and prove the safety.

Various forms of fermented soybean products are well documented for their health benefits. The efficacy of anti-obesogenic effect of Doenjang, one of the most commonly used seasonings in Korean cuisine, has been reported only in animal models; thus, an evaluation of Doenjang needs to be conducted in human studies. We aimed to test the hypothesis that Doenjang supplementation reduces body weight and changes body composition in overweight adults. A total of 51 overweight adults participated in this study. A group of males with BMI ≥ 23 kg/m(2) and waist to hip ratio (WHR) ≥ 0.90, and a group of females with BMI ≥ 23 kg/m(2) and WHR ≥ 0.85 were randomly assigned to either a Doenjang supplement (9.9 g dry/day) group or a placebo group for a 12-week randomized, double-blind and placebo-controlled study. Anthropometric parameters, abdominal fat distribution by computerized tomography (CT) and blood components were measured before and after the intervention period. After the 12-week study, the Doenjang supplementation group had significant reductions in body weight (kg), body fat mass (kg) and body fat (%) compared to the placebo group, the supplementation of Doenjang resulted in a significant reduction in visceral fat (cm(2)), although no changes were observed in total and subcutaneous fat are as (cm(2)), serum lipid profiles and dietary intakes. The present study demonstrated that daily supplementation of 9.9 g dry/day of Doenjang for 12 weeks reduces body weight and visceral fat in overweight adults.