Lessons learned from continued TB outbreaks in a high school.

We investigated the aftereffects of confirmatory QuantiFERON testing (QFT) added to a positive tuberculin skin test (TST). We reviewed the pre and post course of sequential tuberculosis (TB) outbreaks in a high school where massive 43 active TB cases had been found within one year before delayed contact investigation. And we investigated the TB development in relation to initial TST and QFT during mean follow-up of 3.9 ± 0.9 years. After delayed contact investigation for two subsequent TB outbreaks, 925 contacts were divided into the following 3 groups: TST- (n = 632), TST+/QFT+ (n = 24), TST+/QFT- (n = 258). QFT- was more prevalent than QFT+ in contacts with 10mm ≤ TST <15mm (158, 61.2%) compared with TST ≥15mm (100, 38.8%) among the TST+ reactors (P < 0.001). Among the 258 TST+/QFT- subjects, 256 received no latent TB infection (LTBI) treatment, but 7 contacts developed TB during follow-up. Among these 7 patients, 4 had initial TST ≥15mm and 3 had 10mm ≤ TST <15mm. In conclusion, the delayed contact investigation for LTBI in a high school resulted in continued TB developments. False-negative QFT performed late among the TST+ reactors should not be considered criteria for LTBI treatment. Additionally, the contacts only with TST ≥15mm should be considered for LTBI treatment in congregate settings of intermediate-burden countries.

The Prevalence Rate of Tuberculin Skin Test Positive by Contacts Group to Predict the Development of Active Tuberculosis After School Outbreaks.

BACKGROUND: The tuberculin skin test (TST) is the standard tool to diagnose latent tuberculosis infection (LTBI) in mass screening. The aim of this study is to find an optimal cut-off point of the TST+ rate within tuberculosis (TB) contacts to predict the active TB development among adolescents in school TB outbreaks. METHODS: The Korean National Health Insurance Review and Assessment database was used to identify active TB development in relation to the initial TST (cut-off, 10 mm). The 7,475 contacts in 89 schools were divided into two groups: Incident TB group (43 schools) and no incident TB group (46 schools). LTBI treatment was initiated in 607 of the 1,761 TST+ contacts. The association with active TB progression was examined at different cut-off points of the TST+ rate. RESULTS: The mean duration of follow-up was 3.9±0.9 years. Thirty-three contacts developed active TB during the 4,504 person-years among the TST+ contacts without LTBI treatment (n=1,154). The average TST+ rate for the incident TB group (n=43) and no incident TB group (n=46) were 31.0% and 15.5%, respectively. The TST+ rate per group was related with TB progression (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.001-1.050; p=0.037). Based on the TST+ rate per group, active TB was best predicted at TST+ ≥ 16% (OR, 3.11; 95% CI, 1.29-7.51; area under curve, 0.64). CONCLUSION: Sixteen percent of the TST+ rate per group within the same grade students can be suggested as an optimal cut-off to predict active TB development in middle and high schools TB outbreaks.

[Validation of a needs assessment tool for case management in Korean medical aid beneficiaries].

PURPOSE: The purpose of this study was to validate the Needs Assessment Tool for Case Management (NATCM) for use with Korean medical aid beneficiaries. METHODS: Psychometric testing was performed with a sample of 645 Korean medical aid beneficiaries, which included 41 beneficiaries who were selected using proportional sampling method, to examine intraclass correlation coefficients (ICC). Data were evaluated using item analyses, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), Cronbach's alpha, and ICC. RESULTS: Through psychometric testing the final version of NATCM was found to consist of two subscales: 1) Appropriateness of Health Care Utilization (5 items) and 2) Self Care Ability (6 items). The two subscale model was validated by CFA (RMSEA=.08, GFI=.97, and CFI=.93). Internal consistency measured by Cronbach's alpha was .82, and subscale reliability ranged from .79 to .84. The ICC of the NATCM between case managers was .73 and between case managers and health care professionals. .82. CONCLUSION: This study suggests that the final version of NATCM is a brief, reliable, and valid instrument to measure needs of Korean medical aid beneficiaries. Therefore, the NATCM can be effectively utilized as an important needs assessment as well as outcome evaluation tool for case management programs in Korea.

Factors associated with the overuse or underuse of health care services among medical aid beneficiaries in Korea.

PURPOSE: To compare and contrast demographic characteristics and health care service utilization between overusers and underusers of health care services and to identify factors associated with the overuse or underuse of health care services among the medical aid beneficiaries in Korea. METHODS: Secondary data analysis was performed using health care costs and medical aid case management progress data. Data on demographic characteristics, health-related quality of life (HRQoL), and inappropriate health care service user category (overuse or underuse) were provided by the Medical-Aid Case Management Center of Korea, and heath care service reimbursement data were provided by the Korea National Health Insurance Corporation (NHIC). Data on 22,697 beneficiaries were used for analysis, and logistic regression analysis was conducted to examine factors that are associated with overuse and underuse of health care services. RESULTS: The study results revealed that older individuals, women, unemployed individuals, type 1 medical aid beneficiaries, and those with higher education and disabilities were more likely to belong to the overuse group, but urban residents, compared to metropolitan residents, and those with higher HRQoL were more likely to belong to the underuse group (p < .05). CONCLUSIONS: Understanding factors associated with the overuse or underuse of health care services may help to provide tailored case management services to improve the HRQoL of the beneficiaries and optimize their use of health care services. CLINICAL RELEVANCE: Promoting appropriate use of health care services may enhance clients' quality of life and preserve resources for other essential services for medical aid beneficiaries.

Medical Aid service overuse assessed by case managers in Korea.

AIM: This paper is a report of a study conducted to describe characteristics of overusers of the Medical Aid service, assess appropriateness of overusers' medical service use, and determine contributing factors to medical aid overuse in Korea. BACKGROUND: Medical Aid use in Korea has increased in recent years, but no systematic studies reported the characteristics of overusers and appropriateness of their medical service use. METHOD: In a cross-sectional study, case managers conducted interviews, evaluated participants' insurance claim data, and determined overusers by the case managers' determination of the appropriateness of their medical service use and their expenditures during the year of 2006. Descriptive statistics, chi-square analysis, analysis of variance, and multiple logistic regression were used for data analysis. RESULT: Most heavy users were elderly, female, less educated, and had stress, lower perceived health status and multiple clinic visits. Twenty-five per cent of inpatients and 63.9% of outpatients were classified as overusers. The average total cost per capita of an overuser was 43.3% higher than that of an optimal user. Age, education, stress, arthritis, multiple clinic visits and frequent clinic visit recommendations by providers were statistically significant contributing factors to the overuse. CONCLUSION: Preventive measures are needed to decrease the overuse of Medical Aid in Korea; such measures should focus on characteristics contributing to overuse, including the provider-induced demand for more clinic visits. Case managers could play an important role as gatekeepers, managers, and educators for optimal use of Medical Aid in Korea and elsewhere in the world that faces similar problems.

[The medical use of the disabled among overusers of Medical Aid in Korea].

OBJECTIVES: In Korea, the top 10% of Medical Aid recipients represent nearly 60% of total payment, with the costs for those disabled for over 365 days representing approximately 30% of total payment. The purpose of this study was to compare Medical Aid use of the disabled with non-disabled recipients, and to identify contributing factors to the total payment in the top 2% of recipients identified as Medical Aid overusers. METHODS: Subjects (n=2,211) selected were > or =18-years-of-age and received >1000 days of co-payment-free type I Medical Aid. Case managers (n=200) conducted interviews in December 2006, and collected data from Health Insurance Review & Assessment Service. Amounts over the 9 months from January September 2006 were analyzed descriptively and using Chi-square, ANCOVA, and robust multiple linear regression. RESULTS: Disabled individuals (mean age 61.3 years) composed 36.6% of subjects; 44.8% of the disabled were male. On a monthly basis per capita, the disabled group averaged 10.5 outpatient days, total payment of 523,000 Korean Won(), inpatient payment of 359,000, and outpatient payment of 183,000. All values exceeded the monthly average for non-disabled individuals. Contributing factors were identified as male gender (82,000), elementary school or lower educational level (64,000), residence in a small city (82,000), lack of family support (61,000), kidney disability (673,000), intellectual disability (151,000), and multiple disabilities (119,000). CONCLUSIONS: The identification of contributing factors to Medical Aid use by those defined as disabled supports the adoption of comprehensive alternative policies such as strengthening of education and consultation services, provision of alternative facilities, and promotion of self-care.

[The contributing factors to surplus medicine by long-term users of medical aid in Korea].

OBJECTIVES: The amount of medical utilization by Medical Aid recipients was 3.7 times that of patients with Korean Medical Insurance. This study aims to describe the surplus medicine and the medication-related utilization, and to determine factors contributing to surplus medicine. METHODS: Among those who used copayment-free Class I Medical Aid in 2005, 146,880 subjects who were >/=19 year-old and received >365 days medical treatment per year were studied with their case managers by conducting face-to-face interviews. The analytic methods were description, chi-square, t-tests, ANCOVA and multiple logistic regressions. RESULTS: Most subjects were female (68.6%), the elderly (62.5%), and the separated (61.6%), had an elementary graduation or less (74.8%), and had disabilities (33.2%). The percentage of subjects with surplus medicine was 18.5%. However, the percentage of females, the elderly, those with non-disabilities, the separated, the uneducated, those with a very poor perceived health status and those with an economical burden for medical treatment was 19.3%, 18.9%, 19.0%, 19.3%, 19.0%, 20.2% and 24.3%, respectively. For subjects with surplus medicine, averages for the number of used pharmacies, the pharmacy-visit days and the medication costs were 4.6 drugstores, 34.9 days and approximately 1,124 thousand Won(\). These values were higher than those without surplus medicine (4.4 drugstores , 33.8 days, and Won(\)1,110 thousand, respectively). The odds ratios of the contributing factors to surplus medicine were female 1.11 (95% CI=1.07-1.14), the elderly 1.06 (95% CI=1.02-1.10), those with non-disabilities 1.08 (95% CI=1.05-1.12), the separated 1.14 (95% CI=1.10-1.18), the unmarried 1.12 (95% CI=1.07-1.18), the uneducated 1.03 (95% CI=1.01-1.08), those with a very poor perceived health status 1.04 (95% CI=1.01-1.08) and experiencing an economical burden for medical treatment 2.33 (95% CI=2.26-2.40). CONCLUSIONS: 18.5% of subjects had surplus medicine with a higher mean of medication cost. Therefore, health education and health promotion programs to prevent surplus medicine and to improve the appropriate usage of medication are necessary.

Sperm-surface ATP in boar spermatozoa is required for fertilization: relevance to sperm proteasomal function.

Extracellular ATP has been implicated in a number of cellular events, including mammalian sperm function. The complement of ATP-dependent sperm proteins includes six subunits of the 26S proteasome, a multi-subunit protease specific to ubiquitinated substrate-proteins. Proteolysis of ubiquitinated proteins by the 26S proteasome is necessary for the success of mammalian fertilization, including but not limited to acrosomal exocytosis (AE) and sperm-zona pellucida (ZP) penetration. The 26S proteasome is uniquely present on the sperm acrosomal surface during mammalian, ascidian, and invertebrate fertilization. The proteasome is a multi-subunit protease complex of approximately 2 MDa composed of the 19S regulatory complex and a 20S proteolytic core. Integrity of the 19S complex is maintained by six 19S ATPase subunits (PSMC1 through PSMC6). Consequently, we hypothesized that fertilization will be blocked by the depletion of sperm-surface associated ATP (ssATP). Depletion of ssATP by the Solanum tuberosum apyrase, a 49 kDa, non-cell permeant enzyme, significantly reduced the ATP content measured by an adapted luminescence-ATP assay from which all permeabilizing agents were excluded. Addition of active apyrase to porcine in vitro fertilization (IVF) medium caused a concentration dependent reduction in the overall fertilization rate. No such outcomes were observed in control groups using heat-inactivated apyrase. Apyrase treatment altered the band pattern of 19S ATPase subunits PSMC1 (Rpt2) and PSMC4 (Rpt3) in Western blotting, suggesting that it had an effect on the integrity of the sperm proteasomal 19S complex. Apyrase only altered the proteasomal core activities slightly, since these activities are not directly dependent on external ATP. In contrast, sperm treatment with MG132, a specific inhibitor of the proteasomal core chymotrypsin-like activity, inhibited the target proteolytic activity, but also induced a compensatory elevation in proteasomal peptidyl-glutamyl peptide hydrolase activity. Altogether, the present data provide an important missing piece of evidence in support of the ssATP-dependent, proteasomal-proteolytic model of sperm-ZP interactions.

[Trends of nursing science inquiry in doctoral dissertations].

PURPOSE: The purpose of this study was to identify the theoretical characteristics and direction of inquiry in the discipline of nursing by analyzing doctoral dissertations. METHOD: The materials used in this study were 277 doctoral dissertations from five universities in Korea. The framework for the study was derived from Kim's(1993) alternative linkage among philosophy, theory, and method in nursing science. RESULT: Of the 277 dissertations it was found that there were 13 types of linkages out of a possible 54 types. Most of the dissertations (128 of 277) were done within the linkage of realism/etic/quantitative/explanatory knowledge type. Of the 218 dissertations within scientific realism, 42 were within relativism, and 17 within practicism. There were 134 dissertations of the explanatory knowledge type, 112 descriptive ones, and 31 prescriptive ones. Studies done within the etic quantitative methodology included 209 dissertations and within the emic perspective, 43 with qualitative methodology, and 7 with quantitative. CONCLUSION: The results show that it is necessary to develop more alternative linkages for nursing practice and this will lead to expanding nursing knowledge.