Cost-effectiveness of Non-steroidal Anti-inflammatory Drugs Adjusting for Upper and Lower Gastrointestinal Toxicities in Rheumatoid Arthritis Patients

OBJECTIVE: This study was performed to assess the cost-effectiveness of cyclooxygenase-2 (COX2)-selective inhibitor, non-selective non-steroidal anti-inflammatory drugs (NSAIDs), and non-selective NSAID with proton pump inhibitors (PPIs) while considering upper and lower gastrointestinal (GI) safety in patients with rheumatoid arthritis (RA). METHODS: A Markov model was used to estimate the costs and effectiveness. Estimates of therapeutic efficacy and upper/lower GI safety were based on results from large randomized controlled trials. The main outcome measure was cost effectiveness, based on the quality-adjusted life years (QALYs) gained. Safety parameters included clinical upper GI symptoms, uncomplicated ulcer, upper GI bleeding, upper GI perforation, clinical lower GI symptoms, lower GI bleeding, and lower GI perforation. Cost data were obtained from patients treated in a tertiary referral center in Korea. RESULTS: The expected three year cost was 3,052,800 Korean won (KRW) for COX2-selective inhibitor, 3,170,800 KRW for nonselective NSAID, and 3,325,900 KRW for non-selective NSAID with PPI. QALYs were 2.87446, 2.85320, and 2.85815, respectively. The total cost for COX2-selective inhibitor use was lower than non-selective NSAID, but QALY was higher, indicating that the incremental cost effectiveness ratio of COX2-selective inhibitor is superior. CONCLUSION: COX2-selective inhibitor has reasonable cost-effectiveness adjusted for upper and lower GI toxicity for patients with RA in Korea.

Two Cases of Refractory Thrombocytopenia in Systemic Lupus Erythematosus that Responded to Intravenous Low-Dose Cyclophosphamide

Treatment of thrombocytopenia in systemic lupus erythematosus (SLE) is considered in cases of current bleeding, severe bruising, or a platelet count below 50,000/microliter. Corticosteroid is the first choice of medication for inducing remission, and immunosuppressive agents can be added when thrombocytopenia is refractory to corticosteroid or recurs despite it. We presented two SLE patients with thrombocytopenia who successfully induced remission after intravenous administration of low-dose cyclophosphamide (CYC) (500 mg fixed dose, biweekly for 3 months), followed by azathioprine (AZA) or mycophenolate mofetil (MMF). Both patients developed severe thrombocytopenia in SLE that did not respond to pulsed methylprednisolone therapy, and started the intravenous low-dose CYC therapy. In case 1, the platelet count increased to 50,000/microliter after the first CYC infusion, and remission was maintained with low dose prednisolone and AZA. The case 2 achieved remission after three cycles of CYC, and the remission continued with low dose prednisolone and MMF.

A Case of Sarcoidosis Combined with Massive Ascites

Sarcoidosis is a multi-systemic granulomatous disease of unknown cause, which most commonly involves lung, skin, eye, liver and lymph nodes. Herein, we report a case of sarcoidosis presented with massive ascites. A 47-year-old male patient visited our hospital with symptoms of general weakness and weight loss from past 4 months. Abdomen computed tomography showed multiple lymphadenopathy and hepatosplenomegaly. Lymph node biopsy demonstrated non-caseating granulomas. After biopsy, development of massive uncontrolled ascites was noted. Liver biopsy showed non-cirrhotic hepatic and portal fibrosis and omental biopsy showed submesothelial diffuse fibrosis and focal chronic inflammation, which were suggestive of hepatic and peritoneal involvement in sarcoidosis. Ascites was controlled after subsequent treatment with corticosteroids and methotrexate.

A Case of Pulmonary Hemorrhage through Pulmonary Involvement of Henoch-Schonlein Purpura / 대한내과학회지

Henoch-Schonlein purpura (HSP) is an immunologically mediated systemic vasculitis of small blood vessels that primarily involves the skin, gastrointestinal tract, joints, and kidneys. HSP is a relatively common vasculitic syndrome in children, which usually resolves within several weeks, and requires no treatment. The pulmonary parenchymal involvement of HSP is a rare complication that predominantly occurs in adolescents and adults. Mortality following HSP pulmonary presentation is extremely high. Here, we report a case of HSP combined with pulmonary hemorrhage as a presentation of the vasculitic involvement of the lung. Recently, we experienced a case of a 49-year-old male patient with HSP who presented with palpable purpura, enteritis, and glomerulonephritis. Following the diagnosis of HSP, the patient developed sudden pulmonary hemorrhage due to the pulmonary involvement of vasculitis, and recovered following glucocorticoid therapy.

The Correlation between Increased Serum Concentrations of Interleukin-6 Family Cytokines and Disease Activity in Rheumatoid Arthritis Patients

PURPOSE: This study was performed to determine whether the serum concentrations of interleukin (IL)-6 family cytokines are elevated in patients with rheumatoid arthritis (RA) and to investigate the relationship between IL-6 family cytokine levels and disease activity in RA patients. MATERIALS AND METHODS: We obtained serum samples from 40 patients with RA and 40 age- and sex-matched healthy controls, and we assessed the clinical parameters of disease activity, including the 28-joint disease activity score (DAS28) and C-reactive protein (CRP) levels. Serum samples from five patients with high disease activity (DAS28 > 5.1) were also collected at the eighth week of treatment. Serum concentrations of IL-6, IL-11, and leukemia inhibitory factor (LIF) were measured using an enzyme-linked immunosorbent assay (ELISA). RESULTS: Serum concentrations of IL-6 family cytokines, including IL-6, IL-11, and LIF, were significantly elevated in patients with RA compared to those of healthy controls. Although there was no significant relationship between IL-6 family cytokine levels and DAS28, the IL-6 levels of patients with RA showed a significant correlation with CRP levels. After eight weeks of medical treatment in patients with high disease activity, a decrease in DAS28 was associated with a significant decrease in the serum concentrations of IL-6 and IL-11. CONCLUSION: The serum concentrations of IL-6 family cytokines were significantly elevated in patients with RA, and they decreased with medical treatment. These findings suggest a possible role for IL-6 family cytokines in the pathogenesis of RA.

A Case of Sacroiliitis Diagnosed with Positron-Emission Tomography with Normal Magnetic Resonance Imaging Finding / 대한류마티스학회지

No abstract available.

Peroxisome Proliferator-activated Receptor-gamma Agonist Inhibits Pro-inflammatory Gene Expressions and Cellular Proliferation of Fibroblast Like Synoviocytes from Patients with Rheumatoid Arthritis by Down-regulation of NF-kappaB / 대한류마티스학회지

OBJECTIVE: This study investigated the effect of rosiglitazone, a synthetic peroxisome proliferator-activated receptor-gamma (PPAR-gamma) agonist, on pro-inflammatory gene expressions and cellular proliferation of fibroblast like synoviocyte (FLS) from patients with rheumatoid arthritis (RA), and to determine whether these actions are mediated by nuclear factor-kappaB (NF-B) down-regulation. METHODS: Synovial tissues from patients with RA were obtained during total knee replacement surgery, and FLS were isolated. RA FLS were subsequently treated with 10 micrometer, 50 micrometer and 150 micrometer rosiglitazone with or without TNF-alpha (10 ng/mL) stimulation. FLS proliferation in response to rosiglitazone treatment was measured by MTT assay, and mRNA expressions of IL-1beta, IL-6, CCL-2, CCL-7, COX-2 and MMP-9 were determined by real-time quantitative RT-PCR. The effects of rosiglitazone on NF-kappaB activation were evaluated using electrophoretic mobility shift assay (EMSA). RESULTS: Rosiglitazone treatment without TNF-alpha induced a dose-dependent reduction in mRNA expressions of IL-1beta, IL-6, CCL-2, CCL-7, COX-2 and MMP-9 from RA FLS. When TNF-alpha were treated with rosiglitazone, mRNA expressions of COX-2, MMP-9 were reduced dose-dependently. But mRNA expressions of IL-1beta, IL-6, CCL-2, CCL-7 were increased in 10 micrometer rosiglitazone with TNF-alpha and then decreased as the concentration of rosiglitazone increased. Rosiglitazone treatment also suppressed FLS proliferation in a dose-dependent manner, and EMSA showed decreased NF-kappaB expression with rosiglitazone treatment. CONCLUSION: Rosiglitazone suppressed cellular proliferation and mRNA expressions of pro-inflammatory mediators by down-regulating the NF-kappaB signaling pathway in RA FLS. The outcomes suggest that activation of PPAR-gamma can be a novel therapeutic approach in RA.

A Case of Paget's Disease of Bone on Skull / 대한류마티스학회지

No abstract available.

Bone and Cartilage Turnover Markers, Bone Mineral Density, and Radiographic Damage in Men with Ankylosing Spondylitis

PURPOSE: To determine the levels of bone and cartilage turnover markers in men with ankylosing spondylitis (AS) and to investigate their associations with disease activity, bone mineral density, and radiographic damage of the spine. PATIENTS AND METHODS: This cross-sectional study enrolled 35 men with newly diagnosed AS. The bone mineral densities (BMD) of their lumbar spines and proximal femurs, Bath AS Disease Activity Index (BASDAI), and Bath AS Radiographic Index (BASRI) were evaluated. Urinary C-terminal telopeptide fragments of type I collagen (CTX-I) and type II collagen (CTX-II) levels were determined by enzyme-linked immunosorbent assay, and serum levels of bone-specific alkaline phosphatase (BALP) and osteocalcin were determined by an enzyme immunoassay. Levels of biochemical markers were compared with those of 70 age-matched healthy men. RESULTS: Patients with AS had significantly higher mean urinary CTX-I and CTX-II levels than control subjects (p < 0.05). Elevated urinary CTX-I levels correlated well with BASDAI, femoral BMD, and femoral T score (p < 0.05), and elevated urinary CTX-II levels correlated well with spinal BASRI (p < 0.05) in patients with AS. Mean serum BALP and osteocalcin levels did not differ between patients and controls and did not show any significant correlations with BMD, BASDAI, or BASRI in men with AS. Conclusions: Elevated CTX-I reflects disease activity and loss of femoral BMD while elevated CTX-II levels correlate well with radiographic damage of the spine, suggesting the usefulness of these markers for monitoring disease activity, loss of BMD, and radiographic damage in men with AS.

Case of Colonic Polyps with Abdominal Splenosis Mimicking Carcinomatosis / 대한내과학회지

Splenosis is an ectopic implantation of splenic tissue after splenic injury or splenectomy. These splenic implants may be located throughout the abdominal cavity and may be misdiagnosed as a malignancy or tumorous condition. Here, we report a case of splenosis that was initially diagnosed as carcinomatosis from colon cancer in a patient with colon polyps that had undergone explo-laparotomy.

Effects of Substance P Antagonist, D-Arg, D-Phe, D-Trp, Leu- Substance P on the Mechanical Hyperalgesia of Inflammation Induced by Freund's Complete Adjuvant in Rat Paw / 대한마취과학회지

BACKGROUND: The effect of substance P (SP) on the hyperalgesia induced by inflammation is controversial, and as SP remains in the periphery just for a short period of time after release from the nerve ending, the contribution of SP on the development of sustained mechanical hyperalgesia in rats with inflammation is questionable. The purpose of this experiment is to evaluate the effect of SP on the development of mechanical hyperalgesia induced by Freund's complete adjuvant (FCA) using SP antagonist [D-Arg, D-Phe, D-Trp, Leu]-substance P (SPA). METHODS: Male Sprague Dawley rats were divided into four groups; control (normal saline) and three different doses of SPA (0.25 microgram, 2.5 microgram, 25 microgram/0.1 ml). Inflammation was induced in rats by injecting 0.15 ml of FCA intraplantarly. Rats showed typical hyperalgesia within 12 hours after injection and maintained it for about one week. To test the effect of SPA on the developement of inflammation, either SPA or saline was injected at 1 h before and at the time of FCA injection under light halothane anesthesia after a baseline test. The effect of SPA on hyperalgesia was assessed by measuring mechanical hyperalgesia at 2, 6, 12, 24 hrs and 4 days after injection of the drug. To test the effect of SPA on fully developed inflammation, tests were done 2 days after injection of FCA. Mechanical hyperalgesias were assessed at 15, 30, 60, 90, 120 min after the drug injections. RESULTS: SPA injected to suppress the initial SP spill over decreased the mechanical hyperalgesia in a dose dependent manner. SPA injected after the full development of inflammation also decreased mechanical hyperalgesia. CONCLUSIONS: SP released at the initial phase of inflammation as well as SP released after the development of inflammation are all important for the maintainance of mechanical hyperalgesia.

A Suspected Case of Central Anticholinergic Syndrome after N2O-O2-Propofol Anesthesia / 대한마취과학회지

Central anticholinergic syndrome (CAS) is the clinical picture of the central cholinergic blockade. Many drugs used in anesthesia may cause blockade of central cholinergic neurotransmission. Early diagnosis of CAS is very important clinically, CAS's effects are broad and life-threatening. However, it is difficult to find physostigmine in Korea, which is essential to confirm a diagnosis for CAS. An 18-year-old female who was diagnosed with hyperhydrosis underwent a thoracoscopic sympathicotomy. She received N2O-O2-Propofol anesthesia. The anesthesia was unevenful, but postoperatively, she suffered from drowsiness, fever, mydriasis, stiffness of the left upper and lower extremities, and seizures. All tests to seek the cause of CAS such as blood chemistry, brain CT, brain MRI, and CSF test, were normal. She completely recovered without any sequelae after 3 days in ICU. Though it was not confirmed with physostigmine, we report the case to be suspected CAS by all other indications.

Comparison of Epidural Anlagesia with Morphine-Bupivacaine Versus Fentanyl-Bupivacaine after Cesarean Section / 대한마취과학회지

Background: This study was aimed to compare the analgesic effect and side effects of morphine- bupivacaine mixture with those of fentanyl-bupivacaine mixture after Cesarean section. Methods: Eighty patients who were taken continuous epidural catheterization after Cesarean section were divided into two groups. In group 1 (N=40) the mixture of 1% lidocaine 10 ml and morphine 1mg was firstly injected via epidural catheter, and then two day infusor (Baxter(R)) which contained the mixture of 0.15% bupivacaine 100 ml and morphine 6mg was connected to epidural catheter. In group 2 (N=40) the mixture of 1% lidocaine 10 ml and fentanyl 100 mcg was firstly injected via epidural catheter, and then two day infusor (Baxter(R)) which contained the mixture of 0.15% bupivacaine 100 ml and fentanyl 850 mcg was connected to epidural catheter. Mean arterial pressure (MAP) and heart rate (HR) were checked preoperatively, and at post-injection 10, 20, 30 and 60 minutes. The visual analogue scale (VAS) was checked at postoperative 1/2, 1, 6, 12, 24 and 48 hours. The side effects of epidural analgesia were evaluated. Results: In group 2 MAP was significantly decreased at post-injection 20 minute. VAS was significantly increased at post-injection 1/2 and 1 hour in group 1. The most frequent side effect was pruritus in both groups. Conclusions: The first bolus injection of the mixture of 1% lidocaine 10 ml and fentanyl 100 mcg has more rapid analgegic effect than the mixture of 1% lidocaine 10 ml and morphine 2 mg, but because of shorter duration of action of fentanyl it seems to be better to increase the dosage of fentanyl or replace fentanyl by morphine for more effective epidural analgesia after Cesarean section.

Effect of Epidural Dexamethasone Injection for Back Pain after Lumbar Epidural Anesthesia / 대한마취과학회지

Background: Lumbar epidural anesthesia is widely used regional blockade method. But postepidural back pain is most common cause that experienced patients refuse epidural anesthesia. We planned this study to evaluate the effect of epidural dexamethasone injection for postepidural back pain. Methods: Adult patients free of back pain were randomly allocated into two groups. In both group anesthesia was induced with 2% lidocaine 20~25 ml mixed with 1:200,00 epinephrine and fentanyl 0.1 mg. After surgery, epidural catheter was removed after epidural dexamethasone injection in one group (group 2). In other group (group 1), catheter was removed without treatment. We visited patients and asked existence of back pain, and the intensity of back pain was measured by visual analogue scale at 24, 48 and 72 hours after surgery. Statistical analysis was done by Student's t-test and Mann-Whitney test. Results: In group 2, there was significant decrease in number of patients suffering from back pain and intensity of back pain. Conclusion: Epidural dexamethasone injection results in decreased number of patients suffering from back pain and also less in intensity of back pain.

Endotracheal Intubation Using Laryngeal Mask Airway in a Patient with a Difficult Airway: A case report / 대한마취과학회지

Laryngeal mask airway (LMA) was designed as a new concept of airway management in anesthetic practice and has been successfully used in patients with difficult endotracheal intubation due to an abnormal upper airways. When It is in good position, one can cannulate the trachea either blindly or fiberoptic brochoscopically. In a patient with short neck and large breast, we were forced to use an emergency LMA because couldn't insert the laryngoscope. We decided to replace the LMA with an endotracheal tube to secure a definite airway. A fiberoptic bronchoscope was passed through both the endotracheal tube and the LMA to achieve endotracheal intubation. Then we attempted to remove the LMA for safe and smooth awakening. But the LMA coudln't be removed while keeping the LMA and the endotracheal tube in position. Therefore, surgery had to be proceeded with both the LMA and the endotracheal tube in place and all of which were removed after the surgical procedure. We conclude that the LMA is very useful as an aid of endotracheal intubation in patients with difficult airway.

The Effect on Onset Time of Warming Local Anesthetic for Caudal Block / 대한마취과학회지

BACKGROUND: One of the main disadvantages of caudal block is the long latent period before a satisfactory blockade is obtained. Many investigators have used various preparations of local anesthetic solutions to improve the speed of onset. This study was performed to evaluate the effectiveness of prewarming of lidocaine HCl for caudal block. METHODS: Fifty healthy young patients (ASA I) were allocated into two groups, A and B. In group A, the local anesthetic solution were injected at room temperature (25 degrees C), while in group B, they were injected at 37oC. All the caudal block were performed using 2% lidocaine HCl 20 ml with fentanyl 100ug and epinephrine 1:200,000. The onset time was defined as the period from completion of injection until the patient first noticed loss of sensation to pin-prick on perianal region. Assessment of sensory loss was made at 15 seconds interval. We have compared the onset of sensory blockade between groups. The duration of analgesia and any significant side effects were also recorded. RESULTS: The onset of sensory blockade was significantly faster in group B (3.5 +/- 0.5 minutes) than group A (6.2 +/- 0.9 minutes). The duration of analgesia were not significantly changed between groups. Side effects of urinary retention, pruritus and nausea were noted between both groups but the difference was not significant. CONCLUSIONS: We have found that the onset time was 44% faster with warm lidocaine-fentanyl mixture (37 degrees C) than with the room temperature (25 degrees C). The improved clinical usefulness was achieved with no increase in side effects. The technique is a safe and effective method to reduce the latency of onset.