The Degree of Disease Knowledge in Patients with Gastroesophageal Reflux Disease: A Multi-center Prospective Study in Korea

Background/Aims

Patient education has been shown to be beneficial in several diseases. To properly educate patients with gastroesophageal reflux disease (GERD), it is necessary to understand how much they already know about their disease. However, no study has examined the degree of disease knowledge in Korean patients with GERD. Therefore, we conducted this study to assess the degree of knowledge in such patients.

Methods

This multicenter prospective study was conducted from January 2014 to January 2015. A total of 746 patients (mean age, 52 years; 57.6% female) were enrolled from 7 hospitals in Korea. Inclusion criteria were diagnosis of GERD and ability to properly complete a survey. Degree of disease knowledge was assessed using the translated, validated Korean Urnes questionnaire, which consists of 22 items related to GERD.

Results

Mean percentage of correct answers was 46.3% and mean GERD knowledge score was 9.6. Degree of knowledge (mean percentage of correct answers) regarding etiology, prognosis, and treatment of GERD were 49.5%, 36.7%, and 37.5%, respectively. Degree of disease knowledge differed significantly according to age (P < 0.001), education (P < 0.001), income (P = 0.028), and occupation (P < 0.001). In multivariate analysis, using multiple logistic regression, the higher knowledge score group tended to have higher education and professional occupation.

Conclusions

The surveyed Korean patients had relatively low disease knowledge, suggesting that a GERD educational program may be beneficial in Korea. Formulation of a program is underway.

Positive Rates of Preliminary Crossmatches Among Transplantation Candidates Waitlisted for Different Organs in the Korean Network for Organ Sharing

OBJECTIVE

For deceased-donor organ transplantations, negative T cell crossmatches (XMs) are mandatory for kidney and pancreas allocation in the Korean Network for Organ Sharing (KONOS) organ allocation system. Submission and periodic renewal of serum to the KONOS is required for all transplantation candidates of kidney or pancreas and these sera are distributed to 23 laboratories for preliminary XMs. We have investigated how sensitization status varies among transplantation candidates waitlisted for different organs.

METHODS

Positive rates of T cell XMs performed during recent 1-year period (from March 2014 to February 2015) in the Korea Organ Donation Agency laboratory have been analyzed according to different organs. For 163 cases of deceased donors, 3605 recipients (22.1 recipients per one donor) were crossmatched using both of National Institutes of Health and antihuman globulin complement-dependent cytotoxicity (CDC) methods and flow cytometry method.

RESULTS

T cell XM positive rates varied among transplantation candidates for different organs. The positive rate was high for kidney (485/3,145, 15.4%), and low for pancreas or kidney/pancreas (7/200, 3.5%), lung (0/41, 0%), and heart (11/221, 5.0%). Among XM-positive individuals, nearly two-thirds of the kidney transplantation candidates showed strong sensitization status with CDC+/flow+ results (64.5%), whereas pancreas or kidney/pancreas transplantation candidates more commonly showed weaker sensitization status with CDC-/flow+ results (85.7%).

CONCLUSION

Kidney transplantation candidates show a much higher positive rate and stronger sensitization status than candidates for other organs. The results of this study would be useful for determining the number of candidates to be crossmatched for different organs.

[Current issues on gastroesophageal reflux disease]

Gastroesophageal reflux disease (GERD) is one of the most common problems in gastrointestinal disorders. With the increase in our understanding on the pathophysiology of GERD along with the development of proton pump inhibitors, the diagnostic and therapeutic approaches to GERD have changed dramatically over the past decade. However, GERD still poses a problem to many clinicians since the spectrum of the disease has evolved to encompass more challenging presentations such as refractory GERD and extraesophageal manifestations. This has led to significant confusion regarding the optimal approach to these patients. This article aims to discuss current issues on GERD.

Acute pancreatitis secondary to ciprofloxacin therapy in patients with infectious colitis

BACKGROUND/AIMS

Ciprofloxacin is considered to be a safe and effective treatment for acute infectious colitis. However, this drug may cause drug-induced pancreatitis, albeit rarely.

METHODS

From March 2007 to February 2012, we studied 227 patients who were hospitalized for infectious colitis at St. Mary's Hospital. All of the patients received ciprofloxacin therapy for the treatment of infectious colitis. We observed a few cases of rare adverse events, including ciprofloxacin-induced acute pancreatitis diagnosed based on the Naranjo algorithm.

RESULTS

During ciprofloxacin therapy, seven of 227 patients (3.1%) developed rare pancreatitis as defined by the Naranjo algorithm; pancreatic enzyme activity was sporadically elevated with ciprofloxacin use. After ciprofloxacin administration, the average interval until the development of pancreatitis was 5.5 days (range, 4 to 7 days). On abdominal computed tomography, pancreatic swelling and homogenous enhancement was noted in three of seven patients. Complicating acute pancreatitis was gradually but completely resolved after cessation of ciprofloxacin administration. The mean recovery time was 11.3 days (range, 8 to 15 days).

CONCLUSIONS

We observed that ciprofloxacin-induced pancreatitis may occur with an incidence of approximately 3%. Ciprofloxacin-induced pancreatitis presents a short latency, suggesting an idiosyncratic hypersensitivity reaction. Practitioners should be aware that drug-induced pancreatitis can occur during ciprofloxacin therapy.

Anorectal manometric dysfunctions in newly diagnosed, early-stage Parkinson's disease

BACKGROUND AND PURPOSE

Anorectal dysmotility is common in advanced Parkinson's disease (PD), but there have been few evaluations in newly diagnosed PD patients.

METHODS

We conducted anorectal manometric evaluations in 19 newly diagnosed, drug-naïve, early-stage PD patients. All of the PD patients were questioned regarding the presence of anorectal symptoms.

RESULTS

Anorectal manometry was abnormal in 12 of the 19 patients. These abnormalities were more common in patients with more severe anorectal symptoms, as measured using a self-reported scale. However, more than 40% of patients with no or minimal symptoms also exhibited manometric abnormalities.

CONCLUSIONS

These results suggest that anorectal dysmotility manifests in many early-stage PD patients, which this represent evidence for the involvement of neuronal structures in such nonmotor manifestations in PD.

HLA-B*40:179, a novel allele identified by sequence-based typing in cord blood from a Korean woman

The novel allele B*40:179 showed one nucleotide difference with B*40:01:01 in exon 4.

Numb chin syndrome with concomitant painful ophthalmoplegia leading to a diagnosis of diffuse large B cell lymphoma

Painful ophthalmoplegia (PO) and concomitant numb chin syndrome (NCS) is a very rare event. There are a few reports in the literature about PO and concomitant NCS that have preceded the diagnosis of a malignancy. In this report, we describe a patient with diffuse large B cell lymphoma who presented with PO and concomitant NCS as the initial symptom of the disease.

Clinical features of abdominal actinomycosis: a 15-year experience of a single institute

This study was designed to evaluate the clinical features of abdominal actinomycosis and to assess its therapeutic outcome. We reviewed patients with abdominal actinomycosis in Seoul St. Mary hospital, between January 1994 and January 2010. Twenty-three patients (5 male and 18 female, mean age, 47.8 yr; range, 6-75 yr), with abdominal actinomycosis were included. Emergency surgery was performed in 50% due to symptoms of peritonitis. The common presentation on preoperative computerized tomography was a mass with abscess, mimicking malignancy. The mean tumor size was 7.0 cm (range, 2.5-10.5). In all patients, actinomycotic masses were surgically removed. Mean duration of hospital stay was 17.8 days (range, 5-49). Long term oral antibiotic treatment (mean 4.2 months; range, 0.5-7.0 months) were administered to all patients. All patients were free of recurrence after a median follow up of 30.0 months (mean 35.5 ± 14.8 months, range, 10.0-70.0 months); recurrence was not seen in any patient. In conclusion, abdominal actinomycosis should be included as a differential diagnosis when an unusual abdominal mass or abscess presents on abdominal CT. Assertive removal of necrotic tissue with surgical drainage and long term antibiotic treatment provide a good prognosis in patients with actinomycosis.

Anorectal dysfunctions in Parkinson's disease

Anorectal symptoms are frequently found in patients with Parkinson's disease (PD), mainly manifested as diffuse lower abdominal discomfort, constipation, and fecal incontinence. Among these symptoms, constipation may precede by years the motor manifestations of PD. Research has focused for decades on selection of a measurement method for detection of abnormalities and support of clinometric instruments for anorectal symptoms. We review those manifestations and their contribution to evaluation of the anorectal symptoms in patients with PD.

The prevalence and patterns of pharyngoesophageal dysmotility in patients with early stage Parkinson's disease

Dysphagia occurs in the majority of patients with Parkinson's disease (PD) and is known to correlate with abnormalities of oropharyngeal function. The aim of this study was to evaluate pharyngoesophageal activity in patients with early-stage PD. Newly diagnosed PD patients with a symptom duration not exceeding 3 years were included. All PD patients were questioned about symptoms of dysphagia and underwent combined multichannel intraluminal impedance manometry and multiple rapid swallow tests. Fifty-four patients (22 men and 32 women, 67.1 ± 10.3 years) were enrolled. The duration of Parkinsonian motor symptoms was 11.5 ± 8.8 months, the Hoehn and Yahr stage was 1.6 ± 0.4, and the total Unified Parkinson's Disease Rating Scale was 25.1 ± 18.6. Esophageal manometry in the liquid swallow and viscous swallow tests was abnormal in 22 (40.7%) and 31 (67.4%) patients, respectively. Although manometric abnormalities were more common in patients with more severe dysphagia symptoms, many patients with no or minimal symptoms also had manometric abnormalities. Repetitive deglutition significantly correlated with failed peristalsis and incomplete bolus transit. Abnormal responses to multiple rapid swallow tests were found in 33 out of 54 patients; 29 with incomplete inhibition (repetitive contraction) and 4 with failed peristalsis. These results suggest that the majority of patients with early-stage PD showed pharyngeal and esophageal dysfunction even before clinical manifestations of dysphagia, which may reflect selective involvement of either the brain stem or the esophageal myenteric plexus in early-stage PD.

[Change of Clostridium difficile colitis during recent 10 years in Korea]

BACKGROUND/AIMS

Our clinical experience and recent published literatures suggest that Clostridium difficile colitis (CDC) has become more common and potentially more pathogenic in recent years. The aim of study was to evaluate changes in the epidemiological features of CDC in hospitalized patients in Korea.

METHODS

We retrospectively reviewed all patients of CDC diagnosed at Kangnam St. Mary Hospital from 1998 to 2007. CDC was defined as having a positive C. difficile cytotoxicity assay, or endoscopic or pathologic evidence of CDC.

RESULTS

A total of 189 cases (male 73, female 116, mean age 63.3 years) of CDC were diagnosed during the study period. The prevalence of CDC increased from 1.9/10,000 patient admissions in 1998-1999 to 8.82/10,000 patient admissions in 2006-2007. One hundred sixty three indication for cases (86.2%) of patients identified a prior use of antibiotics in the 2 months preceding diagnosis. The most common antibiotic use was prophylactic use during perioperational period (33.3%) followed by pneumonia (23.3%). The overall response rate to initial antibiotics was 82.7%. One hundred seventy two (91%) patients were initially treated with metronidazole. The response rate was 84.3%. All patients with initial failure to metronidazole were successfully treated by vancomycin. The response rate of vancomycin as first treatment was 80%. Three deaths were associated with CDC despite the use of combination of metronidazole and vancomycin.

CONCLUSIONS

The prevalence of CDC in hospitalized patients in Korea significantly increased from 1998 to 2007.

Ambivalent role of gallated catechins in glucose tolerance in humans: a novel insight into non-absorbable gallated catechin-derived inhibitors of glucose absorption

Prolonged postprandial hyperglycemia is a detrimental factor for type 2 diabetes and obesity. The benefit of green tea extract (GTE) consumption still requires confirmation. We report the effects of circulating green tea catechins on blood glucose and insulin levels. Oral glucose loading 1 h after GTE ingestion in humans led to higher blood glucose and insulin levels than in control subjects. Gallated catechins were required for these effects, although within the intestinal lumen they have been known to decrease glucose and cholesterol absorption. Treatment with epigallocatechin-3-gallate hindered 2-deoxyglucose uptake into liver, fat, pancreatic beta-cell, and skeletal muscle cell lines. The glucose intolerance was ameliorated by gallated catechin-deficient GTE or GTE mixed with polyethylene glycol, which was used as an inhibitor of intestinal absorption of gallated catechins. These findings may suggest that the gallated catechin when it is in the circulation elevates blood glucose level by blocking normal glucose uptake into the tissues, resulting in secondary hyperinsulinemia, whereas it decreases glucose entry into the circulation when they are inside the intestinal lumen. These findings encourage the development of non-absorbable derivatives of gallated catechins for preventative treatment of type 2 diabetes and obesity, which would specifically induce only the positive luminal effect.

A synonymous genetic alteration of LMX1B in a family with nail-patella syndrome

The gene responsible for nail-patella syndrome, LMX1B, has recently been identified on chromosome 9q. Here we present a patient with nail-patella syndrome and an autosomal dominant pattern of inheritance. A 17-year-old girl visited our clinic for the evaluation and treatment of proteinuria. She had dystrophic nails, palpable iliac horns, and hypoplastic patellae. Electron microscopy of a renal biopsy showed irregular thickening of the glomerular basement membrane. A family history over three generations revealed five affected family members. Genetic analysis found a change of TCG to TCC, resulting in a synonymous alteration at codon 219 in exon 4 of the LMX1B gene in two affected family members. The same alteration was not detected in an unaffected family member. This is the first report of familial nail-patella syndrome associated with an LMX1B in Korea mutation, However, we can not completely rule out the possibility that the G-to-C change may be a single nucleotide polymorphism as this genetic mutation cause no alteration in amino acid sequence of LMX1B.

Congenital hemidiaphragmatic agenesis presenting as reversible mesenteroaxial gastric volvulus and diaphragmatic hernia: a case report

A 70-yr-old woman complained of left sided chest pain and non-bilious vomiting for four days after taking a gastric bloating agent for an upper gastrointestinal study. The chest radiography revealed gastric air-fluid levels and bowel loops in the left thoracic cavity. An emergency thoracotomy was performed. The abdominal organs (stomach, spleen, splenic flexure of the colon) were in the left thorax and the entire left hemidiaphragm was absent. There were no diaphragmatic remnants visible for reconstruction of the left diaphragm. We provided warm saline irrigation and performed a left lower lobe adhesiotomy. Thirteen days after surgery, the chest radiography showed improvement in the herniation but mild haziness remained at the left lower lung field. Here we present the oldest case of congenital diaphragmatic agenesis presenting with transient gastric volvulus and diaphragmatic hernia.

Polyps in the gastrointestinal tract: discrepancy between endoscopic forceps biopsies and resected specimens

BACKGROUND AND AIM

An endoscopic forceps biopsy (EFB) carries the risk of missing the neoplastic foci within a polyp as only a small portion of the lesion is sampled using this technique. Accordingly, the histological examination of specimens obtained by an EFB is of limited accuracy and patient management based on the histological findings is controversial. The aim of this prospective study was to determine the diagnostic concordance between an EFB and resected tissues of gastric and colon polyps.

METHODS

Between January 2006 and October 2007, 1312 gastrointestinal polyps from 896 patients were resected in our hospital. Patients with polyps of epithelial origin of at least 8 mm in diameter and not associated with polyposis syndromes were included in the study. Polyps of nonepithelial origin were excluded. One thousand two hundred and sixty-four polyps of epithelial origin [gastric polyps (n=268) and colon polyps (n=996)] obtained from 813 patients met the inclusion criteria. All patients underwent an EFB and resection of the polyp by endoscopic mucosal resection and endoscopic submucosal dissection.

RESULTS

Multiple polyps existed in 31.6% of the patients. The pathological diagnoses of resected gastric polyps were as follows: adenomas with low-grade dysplasia, 46 (17.2%); adenomas with high-grade dysplasia, 42 (15.7%); hyperplastic polyps, 126 (47.0%); chronic inflammatory polyps, 29 (10.8%); and adenocarcinomas, 25 (9.3%). The discrepancy rate between an EFB and the pathology of the resected gastric polyps was 39.2% (the Kendall's tau-b and the kappa coefficient for agreement between the EFB and resected specimens of gastric polyps were 0.577 and 0.472, respectively; P value <0.001). No relationship between the size of the gastric polyp and the concordance rate was observed. The pathological diagnoses of the resected colon polyps were as follows: adenomas with low-grade dysplasia, 559 (56.1%); adenomas with high-grade dysplasia, 229 (23.0%); hyperplastic polyps, 44 (4.4%); adenocarcinomas, 53 (5.3%); and inflammatory polyps, 111 (11.1%). The discrepancy rate between the EFB and the pathology of the resected colon polyps was 39.8%. (the Kendall's tau-b and the kappa coefficient for agreement between the EFB and the resected specimens of the colon polyps were 0.479 and 0.293, respectively; P value <0.001). No relationship between the size of the colon polyp and the concordance rate was observed.

CONCLUSION

Considerable discrepancies were observed in histological findings between the EFB and the resected specimens. Therefore, complete removal of the entire polyp is recommended to confirm the diagnosis, to remove precancerous lesions, and to develop an optimal management plan.

A case of post-streptococcal glomerulonephritis with diffuse alveolar hemorrhage

Acute post-streptococcal glomerulonephritis (PSGN) is characterized by an abrupt onset of edema, hypertension, and hematuria. Life-threatening diffuse alveolar hemorrhage (DAH) is rarely associated with acute PSGN. There have been only two reported cases worldwide, and no case has been reported previously in Korea. Here, we present a patient who clinically presented with pulmonary-renal syndrome; the renal histology revealed post-infectious glomerulonephritis of immune complex origin. A 59-yr-old woman was admitted with oliguria and hemoptysis two weeks after pharyngitis. Renal insufficiency rapidly progressed, and respiratory distress developed. Chest radiography showed acute progressive bilateral pulmonary infiltrates. The clinical presentation suggested DAH with PSGN. Three days after treatment with high-dose steroids, the respiratory distress and pulmonary infiltrates resolved. Electron microscopy of a renal biopsy specimen sample revealed diffuse proliferative glomerulonephritis with characteristic subendothelial deposits of immune complex (''hump''). The renal function of the patient was restored, and the serum creatinine level was normalized after treatment.

Successful endoscopic hemoclipping of an esophageal perforation

We describe a case of esophageal perforation that resulted from a fishbone. A 71-year-old man had had a fishbone impacted in the lower esophagus for 2 days. At presentation, the bone was dislodged at endoscopy; one round opening in a deep ulceration was detected when the fishbone was removed. The perforation was closed by endoscopic hemoclipping, after the removal of the fishbone. A thoracic computed tomography revealed air around the esophagus, aorta and bronchus and the presence of a pleural effusion. These findings suggested mediastinal emphysema and mediastinitis due to the esophageal perforation after the removal of the fishbone. Esophagography revealed a focal esophageal defect and linear contrast leakage at the distal esophagus. The mediastinal emphysema and pleural effusion successfully resolved after the endoscopic hemoclip application and conservative management of the perforation.

The papilla of Vater just below the pylorus presenting as recurrent duodenal ulcer bleeding

The papilla of Vater emptying into the duodenal bulb site is extremely rare and considered an aberrant condition. We report here a case with recurrent duodenal ulcer bleeding associated with this anomaly. A 42-year-old man was admitted to St. Mary Hospital because of tarry stool for three days. Despite no documented etiology to explain recurrent ulceration, the patient had about ten episodes of ulcer bleeding since 1995. On duodenoscopy, 1.0 x 0.6 cm sized active stage duodenal ulcer with oozing was observed at the posterior wall side below the pylorus. The papilla of Vater was bulging just below the pylorus. Bile juice was excreted from its opening. Pancreatic duct and common bile duct, which drained into the bulb site, were observed on ERCP. In this report, we show that recurrent duodenal ulcer can be associated with the papilla of Vater just below the pylorus.

Regulation of expression and signalling modulator function of mammalian tribbles is cell-type specific

The constant need to respond to changes in the environment is a common feature for all life forms. During evolution, a number of intracellular signal processing systems have evolved to fulfill this requirement. One of the most ancient such systems is the mitogen activated protein kinase (MAPK) signalling network, shared by all eukaryotes. Activation of MAPKs is key to regulation of mitosis and in cellular responses to stress or hormones, for instance. In addition, activity of this signalling system is essential during embryonic development. However, many aspects of MAPK mediated responses are strongly cell-type specific. A family of proteins, called tribbles have recently been described as novel regulators of MAPK function. Our group has previously shown that alterations in tribbles levels lead to profound changes in the activation of the various MAPKs. However, little is known about the cell-type specific aspects of regulation of tribbles expression. Here, we report that expression of all three members of the human tribbles family is dynamically controlled in response to inflammatory stimulation. This regulation, however, is strongly cell-type dependent. Our observations suggest regulation of tribbles expression may play an important role in the cell-type specific cellular responses, mediated by the MAPK network.

Advancing age and cervical cancer screening and prognosis

OBJECTIVES

To determine associations between advancing age and screening behavior and prognosis in long-term members of a prepaid health plan diagnosed with invasive cervical cancer (ICC).

DESIGN

Case series.

SETTING

Prepaid health plan.

PARTICIPANTS

All women diagnosed with ICC at Kaiser Permanente Medical Care Program-Northern California health plan from 1988 to 1994.

MEASUREMENTS

From medical records, we recorded participants' age, stage at diagnosis, tumor histology, and results of and reasons for all previous cervical smears. We limited our analysis to women who had been members of the health plan for at least 30 of the 36 months preceding diagnosis (n = 455).

RESULTS

Women in older age groups were less likely than younger women to have been screened within the 3 years before diagnosis (P = .005 for trend). Nonadherence to follow-up of abnormal cervical smears was uncommon (17/455, 3.7%) and not age related (P = .932 for trend). The proportions of ICC that were interval cancers, defined as ICC diagnosed within 3 years of a negative screening smear, were highest in women under age 30 (P = .004 for trend). In multivariate analyses controlling for stage at diagnosis, women age 60 and older were not more likely to die of ICC within 3 years of diagnosis than were women younger than age 60 (odds ratio 1.30, 95% confidence interval 0.75-2.28).

CONCLUSION

The disproportionate burden of cervical cancer observed in older women appears to be largely attributable to lack of screening within the 3 years before diagnosis.

Potent fibrinolytic enzyme from a mutant of Bacillus subtilis IMR-NK1

A mutant of Bacillus subtilis IMR-NK1, which is used for the production of domestic "natto" in Taiwan, produced high fibrinolytic enzyme activity by solid-state fermentation using wheat bran as medium. In addition, a strong fibrinolytic enzyme was purified from the cultivation media. The purified enzyme was almost homogeneous, as examined by SDS-PAGE and capillary electrophoresis. The enzyme had an optimal pH of 7.8, an optimal temperature of 55 degrees C, and a K(m) of 0.15% for fibrin hydrolysis. The molecular mass estimated by gel filtration was 31.5 kDa, and the isoelectric point estimated by isoelectric focusing electrophoresis was 8.3. The enzyme also showed activity for hydrolysis of fibrinogen, casein, and several synthetic substrates. Among the synthetic substrates, the most sensitive substrate was N-succinyl-Ala-Ala-Pro-Phe-pNA. PMSF and NBS almost completely inhibited the activity of the enzyme. These results indicate that the enzyme is a subtilisin-like serine protease, similar to nattokinase from Bacillus natto.

Cigarette consumption and sales of nicotine replacement products

BACKGROUND

The first nicotine replacement product, Nicorette Gum, was marketed in 1984 as an adjuvant to help smokers quit smoking. In 1992, sales of nicotine patches were begun. Before 1996, nicotine gums and nicotine patches were prescribed by physicians and supplemented with behavioural counselling. Since 1996, nicotine gums and patches became available over the counter.

OBJECTIVES

To examine the effect of sales of nicotine replacement products on national cigarette consumption.

DESIGN

National time series quarterly cigarette consumption, sales of nicotine gums and patches data between 1976 and 1998 are used to estimate a time series autoregressive moving average intervention model.

PARTICIPANTS

National reported statistics.

MAIN OUTCOME MEASURES

Per capita cigarette sales.

RESULTS

A 10% increase in sales of nicotine replacement products will lead to a 0.04% reduction in cigarette sales. The model indicates that a 0.076% reduction in cigarette consumption is associated with the availability of nicotine patches after 1992. The over the counter dummy variable (after 1996) has a negative sign, but is not significant, perhaps due to only a few quarters of data in the study period.

CONCLUSIONS

Nicotine replacement products (nicotine gums and nicotine patches) play a significant role in reducing cigarette consumption, in addition to the negative effect of increasing cigarette price and the overall trend of declining cigarette consumption (as reflected by the time trend variable). The findings of this study suggest that additional efforts for promoting sales of nicotine replacement products will be another effective alternative to discouraging cigarette consumption.

Papanicolaou smear history and diagnosis of invasive cervical carcinoma among members of a large prepaid health plan

BACKGROUND

Despite the widespread use of Papanicolaou (Pap) smear screening, substantial morbidity and mortality from cervical carcinoma continue in the U.S. Although access to screening is a major barrier to use of the Pap smear, invasive cervical carcinoma (ICC) still is observed in health plan members who have comprehensive preventive care coverage.

METHODS

For all women diagnosed with ICC between 1988 and 1994 in a large prepaid health plan, the authors retrospectively reviewed the medical records for prediagnosis Pap smear history to identify antecedents to ICC.

RESULTS

Of 642 women diagnosed as having ICC, 455 (71%) had been plan members for > or = 30 of the 36 months before diagnosis. Of these 455 women, 240 (53%) had no Pap smear during the 6-36 months prior to diagnosis (i.e., were nonadherent to screening), 127 (28%) had only "normal" Pap smear results, 42 (9%) had at least 1 abnormal Pap smear and were adequately followed, 17 (4%) had at least 1 abnormal result without adequate follow-up, and 29 (6%) were classified as "other." Compared with adherent women, more nonadherent women presented with later stage disease, were symptomatic at the time of diagnosis, were older, and were of a race/ethnicity other than non-Hispanic white.

CONCLUSIONS

Nonadherence to screening recommendations was found to be the most important modifiable antecedent to ICC in this population. The rate of incidence of ICC could be reduced by interventions to increase screening in women who do not have Pap smears regularly and by the use of newer screening technologies to reduce the false-negative rate of Pap smears.

Missed opportunities for cervical cancer screening of HMO members developing invasive cervical cancer (ICC)

OBJECTIVE

To identify potential missed opportunities and to suggest interventions for cervical cancer screening in members of a prepaid health plan by examining the membership histories and medical records of women who had no Pap smear performed in the 3 years prior to the diagnosis of ICC.

METHODS

Medical records of all 642 members of a prepaid health plan developing ICC during the period from 1988 to 1994 were reviewed and details of patient interaction with the health care system were abstracted. Assessment of screening history and history of clinic visits was limited to the period 36 months prior to diagnosis, but excluded the last 6 months prior to diagnosis, so as to avoid including smears or visits which were part of the evaluation that led to the recognition of ICC.

RESULTS

Of women developing ICC, 384/642 (60%) had not had a smear in the period from 36 months to 6 months preceding the diagnosis. Of these 384 unscreened women, 241 (63%) had been insured by our HMO for at least 30 of the 36 months prior to diagnosis. Contact with the medical system in one of the primary care outpatient clinics was documented in 180/241 (75%) of these long-standing members during the specified period. Considering only Internal Medicine and Family Practice clinic visits, 169/241 (70%) had been seen at least once and 101/241 (42%) had been seen 3 or more times.

CONCLUSION

Most long-standing HMO members developing ICC without benefit of recent Pap smear screening were seen in primary care outpatient clinics in the 3 years preceding their diagnosis.

Purification and properties of beta-N-Acetylhexosaminidase from cabbage

beta-N-Acetylhexosaminidase was purified from the extract of cabbage by sequential steps of ammonium sulfate fractionation, chromatofocusing, DEAE-Sepharose CL-6B ion exchange chromatography and Sephacryl S-200 HR gel filtration. By these steps, the purity of the enzyme increased by 256 fold with a recovery of 8%. The purified enzyme was homogeneous as examined by native PAGE. It showed an optimal pH of 4, an optimal temperature of 60 degrees C and a Km of 0.94 mM for hydrolysis of pNp-beta-GlcNAc. The molecular mass of the enzyme determined from filtration through Sephacryl S-200 was 150 kDa. Three subunits with molecular mass of 64, 57 and 51 kDa were observed as determined by SDS-PAGE. NBS (0.025 mM), DEPC (3 mM) and WRK (30 mM) significantly inhibited the activity of the enzyme. The enzyme also showed activity toward pNp-beta-GalNAc, N,N'-diacetylchitobiose, N,N',N"-triacetylchitotriose and N,N',N",N"'-tetraacetyl chitotetraose but showed no activity toward pNp-alpha-GlcNAc, chitin and ethylene glycol chitin.

Persons with chronic conditions. Their prevalence and costs

OBJECTIVES

To determine (1) the number and proportion of Americans living with chronic conditions, and (2) the magnitude of their costs, including direct costs (annual personal health expenditures) and indirect costs to society (lost productivity due to chronic conditions and premature death).

DESIGN

Analysis of the 1987 National Medical Expenditure Survey for prevalence and direct health care costs; indirect costs based on the 1990 National Health Interview Survey and Vital Statistics of the United States.

SETTING

US population.

PARTICIPANTS

For the estimate of prevalence and direct costs, the National Medical Expenditure Survey sample of persons who reported health conditions associated with (1) use of health services or supplies or (2) periods of disability.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The number of persons with chronic conditions, their annual direct health care costs, and indirect costs from lost productivity and premature deaths.

RESULTS

In 1987, 90 million Americans were living with chronic conditions, 39 million of whom were living with more than 1 chronic condition. Over 45% of noninstitutionalized Americans have 1 or more chronic conditions and their direct health care costs account for three fourths of US health care expenditures. Total costs projected to 1990 for people with chronic conditions amounted to $659 billion--$425 billion for direct health care costs and $234 billion in indirect costs.

CONCLUSIONS

The prevalence and costs of chronic conditions as a whole have rarely been estimated. Because the number of persons with limitations due to chronic conditions is more regularly reported in the literature, the total prevalence of chronic conditions has perhaps been minimized. The majority of persons with chronic conditions are not disabled, nor are they elderly. Chronic conditions affect all ages. Because persons with chronic conditions have greater health needs at any age, their costs are disproportionately high.

Purification and properties of chitinase from cabbage stems with roots

Chitinase has been purified from the extract of cabbage stems with roots through successive steps of ammonium sulfate fractionation, Sephadex G-75 gel filtration, chromatofocusing and Sephacryl S-200 HR gel filtration. By these steps, the purity of the enzyme increased by 63 fold and the recovery of the enzyme activity was 18%. The purified enzyme was homogeneous when analyzed by SDS-PAGE. It showed an optimal pH of 6 and optimal temperature of 60 degrees C for hydrolysis of ethylene glycol chitin (EGC). The molecular mass of the enzyme was 41 kDa, as determined by SDS-PAGE. Heavy metal ions (1.5 mM) Ag+, Hg2+ and Fe2+, and chemical modification agents NAI (1 mM), NBS (0.5 mM) and CHD (0.5 mM) significantly or completely inhibited the activity of the enzyme. Substrate EGC at high concentrations also inhibited the activity. BSA (0.05%), Triton X-100 (0.5%) and glycerol (50%) provided significant protection of the enzyme from freezing inactivation.

Do cigarette producers price-discriminate by state? An empirical analysis of local cigarette pricing and taxation

This study analyzes the interactive effects of oligopoly pricing, state taxation, and anti-smoking regulations on retail cigarette prices by state, using panel data for the 50 US states between 1960 and 1990. The results indicate that cigarette producers do price-discriminate by state, though the effect is not large relative to the final retail price. There are two further results: (1) state taxes are more than passed on - a 1-cent state tax increase results in a price increase of 1.11 cents, and (2) sellers offset state and local anti-smoking laws with lower prices, thereby blunting effects of the regulations.

Complete structures of three rice sucrose synthase isogenes and differential regulation of their expressions

By cloning and sequencing cDNA and genomic DNA and transcription initiation site mapping, the total structures including at least 1 kb of putative regulatory sequences upstream of the transcription initiation sites of three genes encoding rice sucrose synthase isoprotomers were either newly established or amended. The third type of SS gene, RSus3, has not been found in other plants. The structures of the three genes and the gene products were compared and their evolutionary sequence was proposed. Specific probes for the three SS mRNA's were developed and used for analyzing their steady state levels at different organs and under some physiological stress conditions. It appears that RSus2 is a house-keeping gene, RSus3 is highly specific to the grain, and the expression of RSus1 shows a tendency to complement that of RSus3. A possible cause of the presence of the third rice SS gene was discussed. We also reported a novel method to synthesize single-stranded DNA for S1 mapping of a transcription initiation site associated with extended secondary structures.

Reducing cigarette consumption in California: tobacco taxes vs an anti-smoking media campaign

OBJECTIVES

The purpose of this study was to examine the relative effects of taxation vs an anti-smoking media campaign on cigarette consumption in California.

METHODS

Quarterly cigarette sales data reported by the California State Board of Equalization between 1980 and 1992 were used to estimate a time-series model, adjusted for seasonal variations and time trends.

RESULTS

The estimated results show that sales of cigarettes were reduced by 819 million packs from the third quarter of 1990 through the fourth quarter of 1992 owing to an additional 25-cent state tax increase, while the anti-smoking media campaign reduced the cigarette sales by 232 million packs during the same period.

CONCLUSIONS

Both taxation and anti-smoking media campaigns are effective means of reducing cigarette consumption. The strength of those effects, however, is influenced by the magnitude of the taxes and the amount of media campaign expenditures.

Transformation of cadmium-binding complexes during cadmium sequestration in fission yeast

Fission yeast responded to environmental cadmium by producing a family of small Cd-binding peptides, phytochelatins (PCn). A low molecular weight (LMW) complex essentially composed of PC2, and PC3 was produced and then disappeared gradually in 24 hrs after Cd treatment, which served as a transient form for a temporary but quick relief of Cd in the cytosoL It had been reported that the LMW complex was further transported into the vacuole by an ABC-type protein (HMT1), and a higher molecular weight (HMW) complex was formed in the vacuole. Results from gel filtration chromatography and HPLC analysis showed that the transformation of the LMW to the HMW complex was accompanied with a rearrangement of its PCn component. Besides, the molecular conformation of the HMW complex changed from a relaxed form in the early stage to a more condensed conformation during cell aging. And the transformation of the LMW into the HMW complex by the addition of sulfide in the test tube was demonstrated.

Purification and characterization of rice sucrose synthase isozymes

From an extract of milk-ripe stage rice grains, four sucrose synthase activities could be separated by a FPLC Mono Q column. They are considered isozymes because they show different electrophoretic mobilities in a non-denaturing gel. However, the migration rates of their subunits in SDS-PAGE were indistinguishable and had a molecular mass of 94 kDa. The native forms had identical molecular mass of 440 kDa, thus they were considered to be tetrameric but carrying different ionic charges. Ouchterlony assay indicates that they have the same epitopes. All isozymes use UDP as the best nucleoside diphosphate substrate. When characterized by the ratio of catalytic rates of sucrose synthesizing and cleaving reactions, the isozyme that had the slowest migration rate in PAGE had the smallest value.

Partial purification and characterization of invertase isozymes from rice grains (Oryza sativa)

Four invertase isozymes have been isolated from the milky stage rice grains. According to the pH optima, they are classified as one alkaline (IT7) and three acid invertases. The acid invertases are further divided into two soluble forms (IT4 and IT5) and one cell wall-bound (ITb) form which was solubilized in 1 M NaCl. The pH optima of ITb, IT4, IT5 and IT7 are 4.5, 3.5-4.0, 5.0 and 7.0, and the molecular masses are 42, 60, 64 and 260 kDa, respectively. Both IT4 and IT5 were bound to Con A-Sepharose suggesting that these enzymes are glycoprotein. The Km of ITb, IT4, IT5 and IT7 for sucrose are 4.3, 0.9, 12.1 and 70.1 mM, respectively. IT4 and IT5 have a higher Km for raffinose, and the maximum activities are 64% and 27% of that using sucrose as the substrate. IT7 did not hydrolyze raffinose at all. These invertases also exhibit distinct isoelectric points (pI) and different susceptibility to various inhibitors.

The hospital response to Medicare's Prospective Payment System: an econometric model of Blue Cross and Blue Shield plans

This paper presents an empirical analysis of the impact that resulted from phase-in of Medicare's Prospective Payment System (PPS) on hospital utilization and payments for the Blue Cross and Blue Shield (BCBS) plans. A pooled cross-sectional time series econometric model was specified and estimated using quarterly hospital utilization and payments of the BCBS plans over the period 1980 to 1987. The results indicate that the implementation of PPS was significantly associated with a lower rate of hospital admissions, days and deflated inpatient payments for the BCBS plan members under age 65. A 1% increase in the proportion of hospital days reimbursed under PPS resulted in a .032% decrease in BCBS plan admissions per 1,000 members, a 0.017% decline in days per 1,000 members and a 0.016% decline in deflated inpatient payment per 1,000 members. The reductions in hospital utilization resulted in lower payments by BCBS plans to participating hospitals suggesting a positive spill-over effect of PPS for private insurers. This research underscores the importance of interaction between federal health policy and the private health insurance market.

Partial purification and characterization of soluble acid invertases from rice (Oryza sativa) leaves

There are three soluble acid invertases in the leaves of rice. They could be separated by DEAE1-Sephacel chromatography, and named IT1, IT2 and IT3. The molecular weights of IT1, IT2 and IT3, determined by HPLC gel filtration chromatography, were 220 kD, 59 kD and 67 kD, respectively. Their pI values were 6.2, 5.2 and 4.9, respectively. The pH optima of IT1, IT2 and IT3 were 3.5, 6.0 and 5.5 respectively. All of them could hydrolyze sucrose and raffinose but not maltose, therefore they are all beta-fructofuranosidases. The apparent Km values for sucrose and raffinose of IT3 were 7.0 and 14.5 mM, respectively. Exogenous protein BSA could activate IT3. IT3 was inhibited by metal ions--Pb2+, Zn2+, Cu2+, Hg2+ and Ag+. The sulfhydryl group inhibitor, PCMB, and serine protease inhibitor, PMSF, had no effects on IT3 activity. It might indicate that cysteine and serine did not participate directly the active site catalytic reaction of IT3.

Purification and characterization of 5'-phosphodiesterase from barley rootlets

A phosphodiesterase was purified from barley rootlets by polyethylene glycol fractionation, calcium phosphate gel-cellulose adsorption, Sepharose CL-4B gel filtration, DEAE-Sepharose CL-6B ion exchange and preparative polyacrylamide gel electrophoresis (PAGE). The enzyme was purified by 103.6 folds and 11% of the enzyme activity was recovered. The purified enzyme was apparently homogeneous when examined on PAGE. It had a molecular weight of 100 kD, an optimum pH of 9.5, and a Km of 0.28 mM on the hydrolysis of p-nitrophenyl thymidine 5'-phosphate. SDS-PAGE revealed that the enzyme molecule might be composed of two or three subunits. Reducing agents, CuSO4, EDTA and 5'-nucleotides were inhibitory to the enzyme activity. This enzyme was able to hydrolyze RNA and denatured DNA efficiently, whereas native DNA was not a good substrate.

Purification and some properties of peroxidase isozymes from pineapple stem

The enzyme peroxidase is widely distributed among the higher plants. Isozymes of peroxidase are known to occur in a variety of tissues in a large number of plant species. In this study, peroxidase isozymes were purified from the extract of pineapple stem through successive steps of ammonium sulfate fractionation, CM-Sepharose CL-6B chromatographies and DEAE-Sepharose CL-6B chromatographies. By these steps, twelve isozymes of peroxidase were obtained. Some properties of the isozymes were studied and compared.

Purification and properties of chitinase from cabbage

Chitinase has been purified from the extract of cabbage through successive steps of ammonium sulfate fractionation, chromatofocusing and Sephadex G-75 gel filtration. By these steps, the purity of the enzyme increased by 93.3 fold and the recovery of the enzyme activity was 20%. The purified enzyme had an optimal pH of 5.0, an optimal temperature between 40 to 50 degrees C and a Km of 76 microM for hydrolysis of ethylene glycol chitin. The molecular weight of the enzyme determined from filtration through Sephadex G-75 was 30,000 daltons. Heavy metal ions, Hg2+ (0.5 mM) and Ag+(2.5 mM) significantly inhibited the activity of the enzyme. NBSI1 (1.0 mM), DNFB (0.5 mM) and PMSF (0.5 mM) completely inhibited the activity of the enzyme. The enzyme also showed muramidase activity for hydrolysis of Micrococcus lysodeikticus cell wall. The presence of chitinase in cabbage may function as a defense enzyme against potential pathogens.

Presence of three rice sucrose synthase genes as revealed by cloning and sequencing of cDNA

By sequencing cDNA clones, we have concluded that three distinct sucrose genes are expressed in rice (Oryza sativa cv. Tainong 67). When the amino acid sequences deduced from these cDNAs as well as those of known sucrose synthase are compared, the highest divergence is found in the C-termini. The most suitable DNA sequences for use as specific for the mRNA derived from these genes have been suggested.

Sucrose synthase in rice plants : growth-associated changes in tissue specific distributions

Different parts of the rice (Oryza sativa L.) plant at different growth stages were analyzed for sucrose synthase (SS) by enzyme activity assay and enzyme-linked immunosorbent assay directly on the extracts or on the eluates from a gel filtration column. On a dry matter basis, the amount of soluble protein and SS activity decreased significantly, but the amount of enzyme protein changed little in growing leaves. In the grain, the SS activity was the highest at the early ripening stage and decreased later, but the amount of SS protein increased with the increase in maturity. In the root, a low activity of SS was detectable only in the tillering but not in other stages. Immunoblotting of SS protein extracted from different parts of rice showed two bands. Elution patterns of crude extracts from a gel filtration column showed the presence of several types of SS protein. Among them, two to three types with larger elution volumes had the SS activity but others with smaller elution volumes (considered as the aggregated forms) had no activity. The SS purified from different parts of the plant showed similar but distinctly different electrophoretic mobilities in a native gel. It has been concluded that different isozymes are expressed in different tissues at different growth stages.

A procedure for purifying jack bean urease for clinical use

Urease with a purity meeting the requirements of analytical use was purified from jack bean meal through steps consisting of 20% acetone extraction, heat treatment, acid precipitation, and lyophilization. For extraction of urease, one part of bean meal was mixed with 5 parts of 20% acetone containing 1 mM EDTA and 1 mM 2-mercaptoethanol, and stirred at 20 degrees C for 5 min. Milky substances in the extract were removed by heat treatment. Urease in the clear yellow supernatant was precipitated by adjusting the pH of the solution to 5.4 with citric acid. The acid precipitated urease was neutralized by dissolving in 0.015 M phosphate buffer, pH 8.5 (final pH 6.8 to 7.0) and then lyophilized. By this procedure, the purity of the enzyme was increase 14.7 fold, the recovery of activity was 63%, and the yield was 6.75 g from 1 kg of bean seeds. The specific activity of the preparation was 411 units/mg protein (240 units/mg solid), and the free ammonia content was less than 0.01 microgram per unit. Some other proteins were present in the urease preparation as examined by gel filtration and gradient polyacrylamide gel electrophoresis. The molecular weight of the enzyme estimated by gel filtration was 480,000. However, two urease activity bands with molecular weight of 230,000 and 480,000 were observed in the polyacrylamide gel electrophoregram. From the result of determination of blood urea nitrogen (BUN), this simple purification procedure could be used for practical preparation of urease from jack bean meal for clinical analysis.

Preparation of pancreatin and purification of lipase from hog pancreas

Pancreatin containing high activities of proteolytic enzymes, amylase and lipase was prepared from optimally autolyzed hog pancreas. About one hundred grams of pancreatin were obtained from one kilogram of hog pancreas. Lipase was purified from the pancreatin preparation through steps of mild alkaline solution extraction, removing proteolytic enzymes by affinity adsorption, first ammonium sulfate fractionation, Sephacryl S-200 gel filtration, and secondary ammonium sulfate fractionation. By these steps, the purity of the enzyme increased 14 fold and the recovery of the enzyme activity was 33%. The purified lipase was not homogeneous and contained several contaminating proteins when examined by disc polyacrylamide gel electrophoresis.

Oven-drying method for polyacrylamide gel slab packed in cellophane sandwich

Polyacrylamide gel slabs can be dried quickly without elaborate tools and the results are similar or even better than those obtained with a commercial drying apparatus. The discontinuous, sodium dodecyl sulfate, and gradient polyacrylamide gel slabs yielded similar results regardless of the staining methods, e.g., Coomassie blue, periodate-Schiff's reagent, or ammoniacal silver.

Enzymatic preparation of seasoning 5'-nucleotides from baker's yeast

Chemical phosphorylation with sodium trimetaphosphate (STMP) as a modifying agent was used to prepare functional protein isolate and dissociated nucleic acid (mostly RNA) from baker's yeast. The majority of protein-RNA complex in the disintegrated yeast cells was first extracted with an aqueous alkaline solution (pH 12, 40 degrees C) followed by phosphorylation with STMP under the same condition for 6 hrs. An apparent dissociation of protein-RNA complex occurred due to the covalent attachment of anionic phosphate groups onto yeast protein molecules. The nucleic acid residued in the supernatant after removal of modified protein isolate by isoelectric precipitation was recovered by reprecipitating at pH 2 followed by converting it to 5'-nucleotides with malt rootlets 5'-phosphodiesterase as well as red marine algal adenylate deaminase. This coherent process provided a preparation of food-usable functional protein isolate and 5'-nucleotides from baker's yeast.