Il-Young Jang

Prevalence of Frailty and Aging-Related Health Conditions in Older Koreans in Rural Communities: a Cross-Sectional Analysis of the Aging Study of Pyeongchang Rural Area

Frailty has been previously studied in Western countries and the urban Korean population; however, the burden of frailty and geriatric conditions in the aging populations of rural Korean communities had not yet been determined. Thus, we established a population-based prospective study of adults aged ≥ 65 years residing in rural communities of Korea between October 2014 and December 2014. All participants underwent comprehensive geriatric assessment that encompassed the assessment of cognitive and physical function, depression, nutrition, and body composition using bioimpedance analysis. We determined the prevalence of frailty based on the Cardiovascular Health Study (CHS) and Korean version of FRAIL (K-FRAIL) criteria, as well as geriatric conditions. We recruited 382 adults (98% of eligible adults; mean age: 74 years; 56% women). Generally, sociodemographic characteristics were similar to those of the general rural Korean population. Common geriatric conditions included instrumental activity of daily living disability (39%), malnutrition risk (38%), cognitive dysfunction (33%), multimorbidity (32%), and sarcopenia (28%), while dismobility (8%), incontinence (8%), and polypharmacy (3%) were less common conditions. While more individuals were classified as frail according to the K-FRAIL criteria (27%) than the CHS criteria (17%), the CHS criteria were more strongly associated with prevalent geriatric conditions. Older Koreans living in rural communities have a significant burden of frailty and geriatric conditions that increase the risk of functional decline, poor quality of life, and mortality. The current study provides a basis to guide public health professionals and policy-makers in prioritizing certain areas of care and designing effective public health interventions to promote healthy aging of this vulnerable population.

Comparisons of predictive values of sarcopenia with different muscle mass indices in Korean rural older adults: a longitudinal analysis of the Aging Study of PyeongChang Rural Area

Purpose It is important to define lean muscle mass when diagnosing sarcopenia, but there is still controversy on the clinical implication of sarcopenia derived by height, weight, and body mass index (BMI) adjusted muscle mass indices. We aimed to evaluate the longitudinal clinical relevance of 3 sarcopenia definitions in the Korean population. Patients and methods We conducted comprehensive geriatric assessments for 1,379 community-dwelling older participants in the Aging Study of PyeongChang Rural Area (ASPRA) cohort and followed them up prospectively for death, institutionalization, and disability every 3 months. Sarcopenia was defined using the Asian Working Group consensus algorithm, combining grip strength, gait speed, and muscle mass. Results Among 1,343 participants (mean age: 76 years, 741 women) analyzed, there were 29 deaths and 89 institutionalizations during 22.0 ± 8.3 months follow-up (mean ± SD). All three muscle indices correlated to age and sex. All sarcopenia criteria with muscle mass indices of height, weight, and body mass index (BMI) adjustment significantly predicted death or institutionalization. However, when adjusted for age and sex, only the sarcopenia criteria with muscle mass index of height adjustment were significantly associated with major adverse health outcomes. Conclusion Adjusting age and gender, the sarcopenia definition from the quintile-based muscle index of height adjustment could predict death or institutionalization in Korean community-dwelling older adults.

Urologic symptoms and burden of frailty and geriatric conditions in older men: the Aging Study of PyeongChang Rural Area

Purpose Frailty is an important consideration in the management of lower urinary tract symptoms and erectile dysfunction in older men; frailty increases vulnerability to treatment-related adverse outcomes, but its burden is not known. The authors aimed to examine the burden of frailty and associated geriatric conditions in community-dwelling older men. Patients and methods A cross-sectional study was conducted with 492 community-dwelling older men (mean age, 74.2 years; standard deviation, 5.6 years). All the participants were administered the International Prostate Symptom Score (IPSS) (range: 0–35) and a five-item version of the International Index of Erectile Function (IIEF-5) (range: 5–25). Frailty phenotype was assessed based on exhaustion, inactivity, slowness, weakness, and weight loss. Prevalence of frailty phenotype and geriatric conditions were assessed by the IPSS severity category (mild, 0–7; moderate, 8–19; severe, 20–35 points) and the first IIEF-5 question, which assesses the confidence in erectile function (low, 1–2; moderate, 3; high, 4–5 points). Results Older men with severe urologic symptoms had a high prevalence of frailty. According to the IPSS questionnaire, the prevalence of frailty was 7.3% (21/288) in the mild category, 16.3% (26/160) in the moderate category, and 43.2% (19/44) in the severe category. Participants in the severe IPSS category showed high prevalence of dismobility (45.5%), multimorbidity (43.2%), malnutrition risk (40.9%), sarcopenia (40.9%), and polypharmacy (31.8%). According to erectile confidence based on the first IIEF-5 question, the prevalence of frailty was 18.7% (56/300) for low confidence, 5.3% (6/114) for moderate confidence, and 5.1% (4/78) for high confidence. Participants with low confidence in erectile function showed high prevalence of sarcopenia (39.0%), multimorbidity (37.7%), dismobility (35.7%), malnutrition risk (33.3%), and polypharmacy (23.0%). Conclusion The prevalence of frailty and geriatric conditions was higher in older men with severe urologic symptoms. A frailty screening should be routinely administered in urology practices to identify older men who are vulnerable to treatment-related adverse events.

Korean version of the Fatigue, Resistance, Ambulation, Illnesses and Loss of weight questionnaire versus the Modified Kihon Checklist for Frailty Screening in Community‐Dwelling Older Adults: The Aging Study of PyeongChang Rural Area

To compare the five‐item Korean version of the Fatigue, Resistance, Ambulation, Illnesses and Loss of weight (K‐FRAIL) questionnaire versus the 28‐item Kihon + 3 index (the 25‐item original Kihon checklist plus multimorbidity, sensory impairment, and Timed Up and Go test) in identifying prefrail or frail older adults.

Eosinophilic organ infiltration without eosinophilia or direct parasite infection.

To the Editor, Eosinophilia is usually defined as the presence of more than 500 eosinophils/mm3 in peripheral blood, and is often accompanied by tissue infiltration [1]. Massive eosinophil infiltration can generate an abscess or granuloma and result in tissue destruction [2]. Focal eosinophilic infiltrations are relatively common in the lung and liver, and are often associated with a parasitic infection, drug hypersensitivity, allergic disease, collagen vascular disease, or malignancy [3]. The presence of peripheral eosinophilia or evidence of direct parasite infestation can provide important insight to assess eosinophilic organ infiltration or abscesses. Most patients diagnosed with eosinophilic abscesses have peripheral blood eosinophilia. Some groups have reported that the number and extent of these foci seemed to be closely related to the eosinophil count in peripheral blood [3]. However, with the exception of eosinophilic infiltration in the gastrointestinal tract, for example in the esophagus or stomach, there have been no previous case reports of patients with eosinophilic organ infiltration without eosinophilia or direct parasitic infestation. Rather, most patients with eosinophilic organ infiltration have moderate to severe eosinophilia (> 1,500/mm3), especial ly primary eosinophilia (clonal eosinophilia or idiopathic hypereosinophilic syndrome) [3,4]. Here, we report a case, detected during regular follow-up due to colon cancer, in a patient with a newly developed eosinophilic liver abscess proven by liver biopsy, and multiple cavitary lesions in both lungs without any evidence of eosinophilia or parasite infection. A 55-year-old female had been diagnosed with ascending colon cancer and had undergone right hemicolectomy followed by six courses of adjuvant 5-fluorouracil chemotherapy. She was regularly followed-up by chest X-ray, abdominopelvic computed tomography (CT) scan, and laboratory tests, including complete blood count, chemistry, and tumor marker (carcinoembryonic antigen, CEA), every 6 months for 4 years at the cancer center in our hospital. There was no evidence of cancer recurrence. At a recent regular visit, multiple newly developed small hepatic lesions in both hepatic lobes were detected on abdominopelvic CT. In addition, numerous cystic and cavitary lesions with multiple nodules were identif ied in both lungs on chest CT. These lesions in the liver and lung were not seen in previous CT scans. She was admitted for further evaluation because of suspected tumor metastasis. However, she had no subjective symptoms, such as itching or fever, and her Eastern Cooperative Oncology Group performance status was zero. No lesions suggestive of malignancy were seen on mammography or gynecological examination, and no skin lesions were revealed by physical examination. On admission, serum eosinophil count was 90/µL, and there had been no eosinophilia for the 4 years since the initial diagnosis of colon cancer. In serological tests, antibodies to Toxocara, Clonorchis, Paragonimus, Cysticercus, and Sparganum all gave negative results, and serum total immunoglobulin E (IgE) was 108 kU/L. Serum CEA was 2.5 ng/mL and was constant. Position emission tomography-CT confirmed the presence of multiple cavitary nodules in both lungs with mild hypermetabolic activity of SUVmax = ~1.2, at the same locations as the lesions seen in chest CT scans. However, there were no hypermetabolic lesions indicative of cancer recurrence or infection in the abdomen. Subsequently, ultrasonography-guided liver core-needle biopsy was performed, targeting the inferior segment of the right lobe where a hypoechoic mass-like lesion was seen. Pathological examination of the biopsy tissue revealed an eosinophilic abscess that contained no malignant cells (Fig. 1). Immunohistochemical staining of the liver tissue also revealed no cells immunopositive for thyroid transcription factor-1, cytokeratin 20, or the homeobox protein CDX2 (a marker of intestinal differentiation). Biopsy confirmation of the multiple cavitary lesions was not possible because of their small size and the risk of complications. Figure 1 Pathological examination of the liver biopsy specimen revealed an eosinophilic abscess that contained no malignant cells (A, HE B, H&E, × 1,000). In a review of past history, the patient denied eating any raw foods, such as bovine liver, minced raw beef, freshwater fishes, or herbal medication. The medication that she had been taking continuously for several years consisted of a β-blocker (bisoprolol), an angiotensin receptor blocker (losartan) for hypertension, and fenofibrate (procetofene) for dyslipidemia. In addition, she had not taken systemic corticosteroids that may have affected her eosinophil blood count during the six courses of 5-fluorouracil chemotherapy. Although there was no evidence of malignancy in the liver biopsy, it was necessary to confirm that the infiltration was due to eosinophils. Therefore, we administered 30 mg of oral prednisolone twice per day for 14 days to determine whether the lesions contracted. In addition, 400 mg of albendazole twice per day for 2 weeks and 1,800 mg of praziquantel three times per day for 2 days were also administered because of the possibility of concurrent parasitic infection. When we performed chest and abdomen CT scans 1 month later, the primary liver lesion had decreased from 14 to 8 mm (Fig. 2), and the number and size of lesions in the lungs were markedly reduced (Fig. 3). After 3 months, CT showed that the lesions in the liver and lungs had almost disappeared without further medication. CT findings 2 years after the patient had presented with eosinophilic organ infiltration revealed no significant lesions in the liver or lungs. Figure 2 Abdominal computed tomography scans. Black arrows indicate lesions with eosinophilic infiltration. Figure 3 Chest computed tomography scans. The cystic and cavitary lesions with multiple nodules seen at diagnosis in both lungs improved over time. Eosinophilia is often accompanied by eosinophilic organ infiltration, especially in the lungs and liver. Previous reports regarding eosinophilic infiltration of organs indicated that eosinophilic infiltration of the esophagus or stomach often occurs without evidence of eosinophilia. However, eosinophilic infiltration of internal organs other than the gastrointestinal tract is almost always accompanied by eosinophilia or direct parasitic infection. In the present case, eosinophilic infiltration of the liver and lungs occurred without any evidence of eosinophilia or direct parasitic infection. Eosinophilic organ infiltration develops in two ways. In the first, it is a consequence of the eosinophilia itself. Moderate to severe eosinophilia often leads to organ infiltration, resulting in organ damage due to the release of cytotoxic granule proteins, such as eosinophil major basic protein and eosinophil cationic protein, as well as inflammatory lipid mediators [3,4]. Irrespective of the cause of the eosinophilic infiltration, the infiltrated organs are the skin, lungs, liver, brain, and most importantly the heart [1,3]. The other cause of eosinophilic organ infiltration is direct parasitic invasion. Some parasitic infections, such as fascioliasis and toxocariasis, produce focal lesions in the hepatic parenchyma due to either direct penetration or hematogenous migration to the liver. These lesions are caused by immature worms arrested during migration, and therefore they contain worms [3]. In the present case, there was no evidence of parasite infestation in the tissue biopsy. Due to the patients history of colon cancer, it was necessary to consider the possibility of cancer recurrence when newly developed multiple nodules were identified in the liver and lungs. There have been anecdotal reports of eosinophilic abscesses mistaken for metastasis and radiological reports of eosinophilic organ infiltration. The nodules in the liver in this case were single, small, and infrequent, consistent with our previous observation that eosinophilic infiltrations in cancer patients involve fewer and smaller nodules than metastatic nodules [5]. Although the lung lesions could not be confirmed by biopsy in this case, they shrank after treatment with oral corticosteroids, indicating that they must also have been eosinophilic infiltrations. In addition, the level of CEA, a marker of colon cancer, also tended to be constant. As the patient had regularly undergone complete blood counts and abdominopelvic and chest CT scans, and had no previous history of systemic corticosteroid treatment, the eosinophilic infiltrations were clearly newly developed. However, their cause remains unclear. A diagnosis of hypereosinophilic syndrome is not appropriate as there was no eosinophilia. The likelihood of a causal relationship with the malignancy is very low, because there was no evidence of tumor recurrence. The possibility of parasite infestation was also low, considering the negative enzyme-linked immunosorbant assay findings, the absence of any history of ingestion of raw food, and the nearly normal serum levels of total IgE [5]. Consequently, we should bear in mind that eosinophilic infiltration in multiple organs can develop without blood eosinophilia or direct parasitic infestation, although its incidence is low.

Advanced POEMS syndrome treated with high-dose melphalan followed by autologous blood stem cell transplantation: a single-center experience.

Background POEMS syndrome is a rare paraneoplastic syndrome associated with plasma cell dyscrasia. High-dose chemotherapy followed by autologous stem cell transplantation has shown encouraging efficacy in the treatment of patients with POEMS syndrome. However, there are minimal reports on clinical outcomes after autologous stem cell transplantation for patients with advanced disease and very poor performance status. Methods We retrospectively evaluated 9 advanced POEMS syndrome patients, who had an Eastern Cooperative Oncology Group performance status score of 3 or 4, and were treated with high-dose melphalan therapy followed by autologous stem cell transplantation from 2004 to 2011. Results Eight patients achieved initial hematologic response, 4 of whom had complete responses. At a median follow-up of 44 months (range, 8-94 months), 7 patients were alive, with 3-year overall survival rate of 77.8%. There were no hematologic relapses in the survivors. One patient died of disease progression; the other died of pneumonia despite a hematologic response 3 months after autologous stem cell transplantation. All survivors achieved improvement in general performance status and in clinical response. Conclusion High-dose melphalan followed by autologous stem cell transplantation can be considered a valid treatment option even for patients with advanced POEMS syndrome.

Wearable device-based walking programs in rural older adults can improve physical activity and health outcome: a feasibility study (Preprint)

Background Community-dwelling older adults living in rural areas are in a less favorable environment for health care compared with urban older adults. We believe that intermittent coaching through wearable devices can help optimize health care for older adults in medically limited environments. Objective We aimed to evaluate whether a wearable device and mobile-based intermittent coaching or self-management could increase physical activity and health outcomes of small groups of older adults in rural areas. Methods To address the above evaluation goal, we carried out the “Smart Walk” program, a health care model wherein a wearable device is used to promote self-exercise particularly among community-dwelling older adults managed by a community health center. We randomly selected older adults who had enrolled in a population-based, prospective cohort study of aging, the Aging Study of Pyeongchang Rural Area. The “Smart Walk” program was a 13-month program conducted from March 2017 to March 2018 and included 6 months of coaching, 1 month of rest, and 6 months of self-management. We evaluated differences in physical activity and health outcomes according to frailty status and conducted pre- and postanalyses of the Smart Walk program. We also performed intergroup analysis according to adherence of wearable devices. Results We recruited 22 participants (11 robust and 11 prefrail older adults). The two groups were similar in most of the variables, except for age, frailty index, and Short Physical Performance Battery score associated with frailty criteria. After a 6-month coaching program, the prefrail group showed significant improvement in usual gait speed (mean 0.73 [SD 0.11] vs mean 0.96 [SD 0.27], P=.02), International Physical Activity Questionnaire scores in kcal (mean 2790.36 [SD 2224.62] vs mean 7589.72 [SD 4452.52], P=.01), and European Quality of Life-5 Dimensions score (mean 0.84 [SD 0.07] vs mean 0.90 [SD 0.07], P=.02), although no significant improvement was found in the robust group. The average total step count was significantly different and was approximately four times higher in the coaching period than in the self-management period (5,584,295.83 vs 1,289,084.66, P<.001). We found that participants in the “long-self” group who used the wearable device for the longest time showed increased body weight and body mass index by mean 0.65 (SD 1.317) and mean 0.097 (SD 0.513), respectively, compared with the other groups. Conclusions Our “Smart Walk” program improved physical fitness, anthropometric measurements, and geriatric assessment categories in a small group of older adults in rural areas with limited resources for monitoring. Further validation through various rural public health centers and in a large number of rural older adults is required.

Usual gait speed is associated with frailty status, institutionalization, and mortality in community-dwelling rural older adults: a longitudinal analysis of the Aging Study of Pyeongchang Rural Area

Purpose We aimed to describe the age- and sex-specific distributions of gait speed and to evaluate associations with longitudinal outcomes in Korean rural community-dwelling older adults. Patients and methods A total of 1,348 people (mean age: 76 years, 55% women) in the population-based, prospective cohort of Aging Study of Pyeongchang Rural Area (ASPRA) between October 2014 and June 2017. All participants underwent a comprehensive geriatric assessment, including 4-m usual gait speed, and were followed annually. Results Among the 1,348 participants, women had a slower gait speed than men (mean 0.709 m/s vs 0.850 m/s, P < 0.001). Gait speed was inversely associated with age, frailty index; slow gait speed as classified by sex-specific quartile was associated with the prevalence of common geriatric syndromes. During the mean follow-up period of 21.5 months (SD 7.88), future survival without mortality or institutionalization was affected by sex-specific gait-speed quartile (log rank test P < 0.001): the 1st quartile of sex-specific gait speed was associated with increased risk of death or institutionalization. Conclusion Gait speed was related to age, sex, frailty status, and geriatric health outcomes in Korean rural community-dwelling older adults. Since this gait-speed distribution in an older Korean population differs from previous data on other populations, we should consider a gait-speed cutoff value based on sex-specific quartiles to prevent misclassification in sarcopenia and frailty diagnosis.