Ability to pay and catastrophic health expenditure of urban and rural deceased households over the past decade (2009-2018).

INTRODUCTION: Examining the equity of health care and financial burden in households of deceased individuals in urban and rural areas is crucial for understanding the risks to both national and individual household finances. However, there is a lack of research on catastrophic health expenditure (CHE) in these households, specifically in urban and rural contexts. This study aims to identify the ability to pay and equity of CHE for both households of deceased individuals in urban and in rural areas. METHODS: This study analysed data from the Korea Health Panel for 10 years (2009-2018) and targeted 869 deceased individuals and their households in the Republic of Korea (South Korea). Annual household income and living costs were adjusted based on equivalent household size, and the difference between these values represented the household's ability to pay. Out-of-pocket (OOP) expenditure included copayments and uninsured healthcare expenses for emergency room visits, inpatient care, outpatient treatments and prescription medications. CHE was defined as OOP expenditure reaching or exceeding 40% of the household's ability to pay. ANCOVA was performed to control for confounding variables, and the equity of CHE prevalence between urban and rural area was assessed using χ2 analysis. RESULTS: Compared to urban households, the rural households of deceased individuals had, respectively, fewer members (2.7 v 2.4, p=0.03), a higher rate of presence of a spouse (63.8% v 70.7%, p=0.04) and a higher economic activity rate (12.7% v 20.5%, p=0.002). The mean number of comordities before death was 3.7 in both urban and rural areas, and there was no difference in the experience of using over-the-counter medicines for more than 3 months, emergency room, hospitalisation, and outpatient treatment. In addition, annual household OOP expenditures in urban and rural areas were US$3020.20 and US$2812.20, respectively, showing no statistical difference (p=0.341). This can be evaluated as a positive effect of various policies and practices aimed at alleviating urban-rural health equity. However, the financial characteristics of the household of the deceased in the year of death differed decisively between urban and rural areas. Compared to urban households, the annual income of rural households (US$15,673.80 v US$12,794.80, respectively, p≤0.002) and the annual ability to pay of rural households (US$14,734.10 v US$12,069.30, respectively, p=0.03) were lower. As a result, the prevalence of CHE was higher in rural areas than in urban areas (68.3% v 77.6%, p=0.003). CONCLUSION: The findings of this study highlight the higher risk of CHE in rural areas due to the lower income level and ability to pay of the household of the deceased. It is evident that addressing the issue of CHE requires broader social development and policy efforts rather than individual-level interventions focused solely on improving health access and controlling healthcare costs. The findings of this study contribute to the growing evidence that income plays a crucial role in rural health outcomes.

Socioeconomic class and antenatal and postpartum care inequality in the viewpoint of Korea's response to the low fertility rate.

The author pays attention to the low total fertility rate (0.78 in Korea in 2022) and inequality in antenatal and postpartum care between socioeconomic classes. I analyzed the data of the Korea Health Panel (2008-2016), 1,196 postpartum women. Low-income households have low fertility rates and less experience with antenatal and postpartum care, and postpartum care costs tend to be time-series lower than others. In order to solve the problem of low fertility due to economic burden, policy governance should focus on equity in antenatal and postpartum care. This is to go beyond women's health and ultimately contribute to social health.

Comparison of out-of-pocket expenditure and catastrophic health expenditure for severe disease by the health security system: based on end-stage renal disease in South Korea.

BACKGROUND: Korea's health security system named the National Health Insurance and Medical Aid has revolutionized the nation's mandatory health insurance and continues to reduce excessive copayments. However, few studies have examined healthcare utilization and expenditure by the health security system for severe diseases. This study looked at reverse discrimination regarding end-stage renal disease by the National Health Insurance and Medical Aid. METHODS: A total of 305 subjects were diagnosed with end-stage renal disease in the Korea Health Panel from 2008 to 2013. Chi-square, t-test, and ANCOVA were conducted to identify the healthcare utilization rate, out-of-pocket expenditure, and the prevalence of catastrophic expenditure. Mixed effect panel analysis was used to evaluate total out-of-pocket expenditure by the National Health Insurance and Medical Aid over a 6-year period. RESULTS: There were no significant differences in the healthcare utilization rate for emergency room visits, admissions, or outpatient department visits between the National Health Insurance and Medical Aid because these healthcare services were essential for individuals with serious diseases, such as end-stage renal disease. Meanwhile, each out-of-pocket expenditure for an admission and the outpatient department by the National Health Insurance was 2.6 and 3.1 times higher than that of Medical Aid (P < 0.05). The total out-of-pocket expenditure, including that for emergency room visits, admission, outpatient department visits, and prescribed drugs, was 2.9 times higher for the National Health Insurance than Medical Aid (P < 0.001). Over a 6-year period, in terms of total of out-of-pocket expenditure, subjects with the National Health Insurance spent more than those with Medical Aid (P < 0.01). If the total household income decile was less than the median and subjects were covered by the National Health Insurance, the catastrophic health expenditure rate was 92.2%, but it was only 58.8% for Medical Aid (P < 0.001). CONCLUSION: Individuals with serious diseases, such as end-stage renal disease, can be faced with reverse discrimination depending on the type of insurance that is provided by the health security system. It is necessary to consider individuals who have National Health Insurance but are still poor.

Association between domperidone use and adverse cardiovascular events: A nested case-control and case-time-control study.

PURPOSE: To assess the association between domperidone and adverse cardiovascular events. METHODS: We conducted nested case-control and case-time-control studies using Korea's healthcare database (2002-2015). We identified patients without history of hospitalization, cancer, or cardiovascular diseases in 2002. From our cohort, those diagnosed with an adverse cardiovascular event (case), composite of arrhythmia, hypertension, or acute myocardial infarction were matched to two controls using risk-set sampling on various sociodemographic variables. Exposure was assessed in the 1 to 7 days, or in the 1 to 7 days (hazard period) and 91 to 97 days (control period) prior to index date, in nested case-control and case-time control studies, respectively. We compared domperidone to metoclopramide or non-use and estimated odds ratios (OR) with 95% confidence intervals (CI) using conditional logistic regression. RESULTS: From 627 799 patients, we identified 71 555 cases and 141 833 controls. In the nested case-control study, while the risk of cardiovascular events was increased with domperidone (OR 1.38, 95% CI 1.28-1.47) compared to non-use, the risk was reduced (0.64, 0.57-0.72) compared to metoclopramide. In the case-time-control study, similar increased risk was found when compared to non-use (1.40, 1.29-1.52) but a reduced risk as compared with metoclopramide (0.63, 0.54-0.72). Risk of myocardial infarction associated with domperidone was highest (nested case-control: 1.94, 1.33-2.83; case-time-control: 1.91, 1.01-3.62) when compared to non-use but did not indicate an increased risk when compared to metoclopramide (nested case-control: 0.60, 0.32-1.13; case-time-control: 0.70, 0.25-1.98). CONCLUSION: Our findings support a positive association between domperidone and adverse cardiovascular events. However, domperidone may have a safer cardiovascular profile than metoclopramide.

Regulatory effect of decreasing therapeutic duplication of respiratory drugs using a prescription database between 2012 and 2015.

Duplicative drug use increases the risk of adverse drug reactions and expends healthcare resources unnecessarily. No epidemiological evidence of the prevalence of therapeutic duplication (TD) involving respiratory system drugs exists. Therefore, we describe the prescription patterns of these drugs and estimate changes in TD rates following implementation of a new regulation in 2013. A time-series analysis using national healthcare data was conducted, involving eight classes, and patients prescribed any of these drugs between 2012 and 2015. We used two definitions of TD; duplicative prescriptions overlapped for more than 30 days by the same prescriber and for more than 1 day by different prescribers. We calculated relative and absolute difference in TD rates after the regulation. TD by the same prescriber decreased for respiratory drugs of six classes, but increased more than 10% for antihistamines (+10.28, +0.05). TD by a different prescriber decreased only for xanthine bronchodilators, but increased more than 10% for beta-receptor agonists (+27.07, +1.42), leukotriene receptor antagonists (+16.10, +0.44), cough suppressants (+15.64, +0.52), mucolytic agents (+11.16, +0.67). The 2013 regulation regarding respiratory drugs did not have the anticipated effect of reducing TD prevalence; more effective interventions are needed.

Physician and pharmacist satisfaction and clinical needs for the real-time medication surveillance program in South Korea.

BACKGROUND: Since December 2010, a nationwide real-time medication surveillance program has been implemented in Korea to prevent potential adverse drug reactions. Our goal was to evaluate physicians' and pharmacists' satisfaction and clinical needs for the medication surveillance program in Korea. METHODS: Both web- and paper-based surveys were conducted using a structured questionnaire among 1164 physicians and pharmacists from May 23, 2014 to August 11, 2014. The survey consisted of questions about the participant's satisfaction with the medication surveillance program, clinical usefulness, clinical need for the medication surveillance program, and sociodemographic characteristics. Multivariate ordinal logistic regression was performed to investigate the factors influencing satisfaction levels with the medication surveillance program. RESULTS: We analyzed data from 1120 respondents, including 503 physicians and 617 pharmacists. Overall, 63.1% of the respondents were satisfied with the medication surveillance program. Pharmacists were more satisfied with the program than were physicians (69.1% vs. 55.6%; adjusted odds ratio, 2.13; 95% confidence interval, 1.65-2.76). Among the respondents, 77.8% cited a decrease in therapeutic duplication to be a major improvement resulting from the medication surveillance program, 82.6% considered the drug-drug interaction information useful, and 48.7% suggested that the program should include information on liver or kidney disease-drug interaction. CONCLUSIONS: Overall, 63.0% of physicians and pharmacists were satisfied, and a decrease in therapeutic duplication was regarded as the most beneficial component. Further improvements by considering clinical needs of physicians and pharmacists will be needed to increase satisfaction.

Factors associated with intention to be tested for HIV among men who have sex with men in a country with a very low HIV prevalence.

This study examined factors associated with the intention to take an HIV test among men who have sex with men (MSM) in South Korea. An internet website-based survey was conducted among users of the only and largest online MSM website between 20 July 2016, and 20 August 2016. A total of 2915 participants completed the survey and answered questions related to sociodemographic information, health behaviors, sexual behaviors, and HIV testing history. Of these, 2587 (88.7%) participants responded as having an intention to take an HIV test. A multivariable logistic regression analysis revealed the following as having reduced the intention to undergo HIV testing: very good subjective health status and no sexual interactions during the last 6 months (Adjusted odds ratios [AOR] 0.45 and 0.54, respectively). In contrast, increased intention to take an HIV test was associated with being 20-29 years old, 30-39 years old, not paying or receiving money for sex, having a history of HIV testing, and taking an HIV test once per 12 months (AOR 2.64, 2.13, 1.54, 1.81, and 2.17, respectively). In conclusion, HIV testing among MSM in this study was associated with age, subjective health status, sex(es) of one's sexual partner(s) during the last 6 months, sexual risk behaviors, HIV testing history, and undergoing regular HIV testing.

Effect of providing drug utilization review information on tricyclic antidepressant prescription in the elderly.

Tricyclic antidepressants are known as potentially inappropriate medications in the elderly. A notification issued in July 2015 in South Korea recommended caution while prescribing tricyclic antidepressants to the elderly. Further, since October 2015, the nationwide computerized drug utilization review monitoring system provides a pop-up window, on a real-time basis, whenever tricyclic antidepressants are prescribed to elderly outpatients. Therefore, we evaluated whether providing drug utilization review information was effective in reducing tricyclic antidepressant prescription to elderly outpatients. We used the Health Insurance Review and Assessment Service-Adult Patient Sample data from 2014 to 2016. Data related to the prescription of tricyclic antidepressants to outpatients aged 65 years or more were extracted. We determined the number of prescriptions per day per 100,000 elderly patients in each month, compared the average number of prescriptions before and after the drug utilization review information was provided, and evaluated the changes in the number of prescriptions by using an interrupted time series analysis. The average number of tricyclic antidepressant prescriptions per day per 100,000 elderly patients decreased from 76.6 (75.5 to 77.6) to 65.7 (64.5 to 66.9), a 14.2% reduction after the provision of drug utilization review information started. Following initiation of provision of drug utilization review information, there was an immediate drop of 9.2 tricyclic antidepressant prescriptions per day per 100,000 elderly patients, whereas there was no statistically significant change in trends. Providing the drug utilization review information on tricyclic antidepressant prescription for the elderly contributed to the reduction in tricyclic antidepressant prescriptions.

TM0416, a Hyperthermophilic Promiscuous Nonphosphorylated Sugar Isomerase, Catalyzes Various C5 and C6 Epimerization Reactions.

There is currently little information on nonphosphorylated sugar epimerases, which are of potential interest for producing rare sugars. We found a gene (the TM0416 gene) encoding a putative d-tagatose-3-epimerase-related protein from the hyperthermophilic bacterium Thermotoga maritima We overexpressed the TM0416 gene in Escherichia coli and purified the resulting recombinant protein for detailed characterization. Amino acid sequence alignment and a structural similarity search revealed that TM0416 is a putative nonphosphorylated sugar epimerase. The recombinant enzyme exhibited maximal C-3 epimerization of l-ribulose to l-xylulose at ∼80°C and pH 7 in the presence of 1 mM Mn2+ In addition, this enzyme showed unusually high activity for the epimerization of d-tagatose to d-sorbose, with a conversion yield of 20% after 6 h at 80°C. Remarkably, the enzyme catalyzed the isomerization of d-erythrose or d-threose to d-erythrulose significantly, with conversion yields of 71% and 54.5%, respectively, after 6 h at 80°C at pH 7. To further investigate the substrate specificity of TM0416, we determined its crystal structures in complex with divalent metal ions and l-erythrulose at resolutions of 1.5 and 1.6 Å. Detailed inspection of the structural features and biochemical data clearly demonstrated that this metalloenzyme, with a freely accessible substrate-binding site and neighboring hydrophobic residues, exhibits different and promiscuous substrate preferences, compared with its mesophilic counterparts. Therefore, this study suggests that TM0416 can be functionally classified as a novel type of l-ribulose 3-epimerase (R3E) with d-erythrose isomerase activity.IMPORTANCE Rare sugars, which occur naturally in small amounts, have attracted considerable attention in the food and drug industries. However, there is little information on nonphosphorylated sugar epimerases, which might potentially be applied for the production of rare sugars. This study describes the characterization and functional annotation of a putative nonphosphorylated sugar 3-epimerase from a hyperthermophilic bacterium. Furthermore, we determined its crystal structures in complex with divalent metal ions and l-erythrulose, highlighting its metal-dependent, bifunctional, sugar-isomerizing activity. This hyperthermophilic R3E exhibited d-erythrose/d-threose isomerase activity, with structural features near the substrate-binding site distinct from those of its mesophilic counterparts. Moreover, this metalloenzyme showed unusually high activity for the epimerization of d-tagatose to d-sorbose at 70°C. Therefore, TM0416 can be functionally classified as a novel type of promiscuous R3E with a potential for the production of rare sugars for the food and pharmaceutical industries.

Antibiotic Use in Children - A Cross-National Analysis of 6 Countries.

OBJECTIVES: To describe the rates of pediatric antibiotic use across 6 countries on 3 continents. STUDY DESIGN: Cross-national analysis of 7 pediatric cohorts in 6 countries (Germany, Italy, South Korea, Norway, Spain, and the US) was performed for 2008-2012. Antibiotic dispensings were identified and grouped into subclasses. We calculated the rates of antimicrobial prescriptions per person-year specific to each age group, comparing the rates across different countries. RESULTS: A total of 74 744 302 person-years from all participating centers were included in this analysis. Infants in South Korea had the highest rate of antimicrobial consumption, with 3.41 prescribed courses per child-year during the first 2 years of life. This compares with 1.6 in Lazio, Italy; 1.4 in Pedianet, Italy; 1.5 in Spain; 1.1 in the US; 1.0 in Germany; and 0.5 courses per child-year in Norway. Of antimicrobial prescriptions written in Norway, 64.8% were for first-line penicillins, compared with 38.2% in Germany, 31.8% in the US, 27.7% in Spain, 25.1% in the Italian Pedianet population, 9.8% in South Korea, and 8% in the Italian Lazio population. CONCLUSIONS: We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.

Structure of the thermophilic l-Arabinose isomerase from Geobacillus kaustophilus reveals metal-mediated intersubunit interactions for activity and thermostability.

Thermophilic l-arabinose isomerase (AI), which catalyzes the interconversion of l-arabinose and l-ribulose, can be used to produce d-tagatose, a sugar substitute, from d-galactose. Unlike mesophilic AIs, thermophilic AIs are highly dependent on divalent metal ions for their catalytic activity and thermostability at elevated temperatures. However, the molecular basis underlying the substrate preferences and metal requirements of multimeric AIs remains unclear. Here we report the first crystal structure of the apo and holo forms of thermophilic Geobacillus kaustophilus AI (GKAI) in hexamer form. The structures, including those of GKAI in complex with l-arabitol, and biochemical analyses revealed not only how the substrate-binding site of GKAI is formed through displacement of residues at the intersubunit interface when it is bound to Mn(2+), but also revealed the water-mediated H-bonding networks that contribute to the structural integrity of GKAI during catalysis. These observations suggest metal-mediated isomerization reactions brought about by intersubunit interactions at elevated temperatures are responsible for the distinct active site features that promote the substrate specificity and thermostability of thermophilic AIs.

The structural basis of substrate promiscuity in UDP-hexose 4-epimerase from the hyperthermophilic Eubacterium Thermotoga maritima.

UDP-galactose 4-epimerase (GalE) catalyzes the interconversion of UDP-glucose (UDP-Glc) and UDP-galactose (UDP-Gal), which is a pivotal step in the Leloir pathway for d-galactose metabolism. Although GalE is widely distributed in prokaryotes and eukaryotes, little information is available regarding hyperthermophilic GalE. We overexpressed the TM0509 gene, encoding a putative GalE from Thermotoga maritima (TMGalE), in Escherichia coli and characterized the encoded protein. To further investigate the molecular basis of this enzyme's catalytic function, we determined the crystal structures of TMGalE and TMGalE bound to UDP-Glc at resolutions of 1.9 Å and 2.0 Å, respectively. The enzyme was determined to be a homodimer with a molecular mass of 70 kDa. The enzyme could reversibly catalyze the epimerization of UDP-GalNAc/UDP-GlcNAc as well as UDP-Gal/UDP-Glc at elevated temperatures, with an apparent optimal temperature and pH of 80 °C and 7.0, respectively. Our data showed that TM0509 is a UDP-galactosugar 4-epimerase involved in d-galactose metabolism; consequently, this study provides the first detailed characterization of a hyperthermophilic GalE. Moreover, the promiscuous substrate specificity of TMGalE, which is more similar to human GalE than E. coli GalE, supports the notion that TMGalE might exhibit the earliest form of sugar-epimerizing enzymes in the evolution of galactose metabolism.

Regulatory action and moderate decrease in methylphenidate use among ADHD diagnosed patients aged five and under in Korea.

In December 2009, Korean regulatory agency announced that methylphenidate, a drug used to treat attention deficit-hyperactivity disorder (ADHD), should not be used in children aged five and under due to the risk of sudden cardiac death. This study examined the impact of regulatory action and prescribing patterns. We conducted a time series analysis using the Korea National Health Insurance Service database. Study subjects included children under 18years old with ADHD from January 2007 to December 2011. Contraindicated use of methylphenidate was defined as use of methylphenidate at least once in children aged five and under. We selected additional control points (2007, 2008, and 2010) and compared the methylphenidate use one year before and after each point. We calculated relative and absolute reductions, and 95% confidence intervals. The total number of ADHD patients was 376,298. Overall, there was a 70.87% relative reduction (95% CI: 63.33%-79.31%) and a 0.93% absolute reduction (95% CI: 0.51%-0.60%) of methylphenidate use. The relative and absolute reductions were 27.61% (95% CI: 24.76%-30.78%) and 0.31% (95% CI: 0.21%-0.41%) in 2007; 43.58% (95% CI: 38.02%-49.96%) and 0.35% (95% CI: 0.27%-0.43%) in 2008; 46.52% (95% CI: 38.86%-55.70%) and 0.21 (95% CI: 0.15%-0.27%) in 2009; and 10.20% (95% CI: 8.32%-12.50%) and 0.02% (95% CI: 0.02%-0.07%) in 2010. Korean regulatory action led to a moderate decrease in contraindicated methylphenidate use even after the steep decline before the regulatory action.

Prescribing patterns of the four most commonly used sedatives in endoscopic examination in Korea: propofol, midazolam, diazepam, and lorazepam.

As the sedative use increases due to the effectiveness and relatively safe profile, the abuse potential is also increasing. This study was conducted to examine the usage of four sedative agents in endoscopic examination and to compare the propofol use with the other three sedatives. Using National Health Insurance claims data from 2008 to 2012, we identified the number of cases of conscious sedation during endoscopy using one or more of the following agents: propofol, midazolam, diazepam, and lorazepam. The general characteristics of patients and medical service providers were analyzed, and the regional and annual distributions of frequency of use were compared. We also identified patient cases with excessive number of endoscopic examinations. Among the total of 3,156,231 sedatives users, midazolam was the most commonly used agent (n=2,845,250, 90.1%). However, the largest increase in patient number, which increased from 11,410 in 2008 to 28,170 in 2012, was observed with propofol. While the majority of patients received an annual endoscopy, we identified several suspected abuse cases of patients receiving endoscopies repetitively as many as 114 times in five years. The rise of sedative use in endoscopic examinations and several patient cases of repeated sedative administration suggest a potential risk for abuse. Medical service providers should be cautious when using sedatives and carefully review each patient's medical history prior to the procedure.

Postpartum Uterine Bleeding from the Inferior Mesenteric Artery: Case Report and Review of the Literature.

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. The common causes of primary PPH include uterine atony, abnormal placentation, retained placenta, and birth canal injury. The inferior mesenteric artery (IMA) arises from the aorta and is the main artery to supply the descending and sigmoid colon, as well as the rectum. We present a case of immediate, severe uterine bleeding after a normal vaginal delivery; angiography determined that hemorrhage originated from the IMA, and there were no anastomoses between the IMA and other pelvic arteries. The patient was successfully managed by selective embolization of a distal branch of the IMA. Our case report presents a new and interesting variation of pelvic vascular anatomy; moreover, it is the first report to present a case of postpartum uterine bleeding originating from the IMA.

Prevalence of antibiotic use for pediatric acute upper respiratory tract infections in Korea.

This study was conducted to estimate the prevalence of antimicrobial prescribing for acute upper respiratory tract infections (URI) among pediatric outpatients and to identify the national patterns of its use from 2009 to 2011 in Korea. Using National Patients Sample database from 2009 to 2011, we estimated the frequency of antibiotics prescribing for URI in pediatric outpatients with diagnoses of acute nasopharyngitis (common cold), acute sinusitis, acute pharyngitis, acute tonsillitis, acute laryngitis/tracheitis, acute obstructive laryngitis/epiglottitis, and acute upper respiratory infections of multiple and unspecified sites. The proportions of each antibiotic class were calculated by year and absolute and relative differences were estimated. Also, we investigated daily amount of prescribed antibiotics per defined population according to the type of medical care institution, physician specialty, and geographic region. The overall antibiotic prescribing proportion was 58.7% and its annual proportion slightly decreased (55.4% in 2011 vs. 60.5% in 2009; adjusted odds ratio, 0.82; 95% confidence interval, 0.82-0.83). Variations by the type of medical care institution were observed. Tertiary hospitals (45.0%) were less likely to prescribe antibiotics than primary care clinics (59.4%), hospitals (59.0%), and general hospitals (61.2%); they showed different tendencies in choosing antibiotics. Variations by physician specialty and region were also observed. Prevalence of antimicrobial prescribing for pediatric URI is still considered higher than that of western countries and varies by the type of medical care institution, physician specialty, and geographic region.

Dramatic decrease in fluoroquinolones in the pediatric population in Korea.

PURPOSE: This study was performed to evaluate the change of prescribing patterns after the regulatory action regarding fluoroquinolones in pediatric patients. METHODS: We conducted a time series analysis using the Korea Health Insurance Review and Assessment Service National Patients Sample database. Study subjects consisted of pediatric patients under 18 years of age who were prescribed antibiotics at least once (ATC code, J01) before (January 2009-December 2009) and after implementation (January 2010-December 2011) of the regulation. The use of fluoroquinolones was defined as the use of the following antibiotics for at least once in pediatric patients: ofloxacin, ciprofloxacin, norfloxacin, lomefloxacin, levofloxacin, and gemifloxacin. We calculated the number of pediatric fluoroquinolone users for each month. The difference between proportions before and after the regulation was estimated as relative and absolute reduction of fluoroquinolone use. We calculated 95% confidence intervals (CI). RESULTS: We identified 4, 945, 169 antibiotic prescriptions in 484, 914 pediatric patients. During the 12-month period before implementation, percentage of fluoroquinolone use was 4.81% (95% CI: 4.70-4.91%, N = 8001). We observed a rapid decrease in the monthly number of fluoroquinolone users in pediatric population after the implementation of regulatory action. In the year after regulatory action, the percentage of fluoroquinolone use was only 0.26% (95% CI: 0.24-0.28%, N = 834). Overall, there was a 94.55% relative reduction (95% CI: 88.02-101.56%) in the use of fluoroquinolones. CONCLUSION: Korean regulatory actions regarding fluoroquinolones had an effect of reducing use in pediatric population.

Household catastrophic health expenditure related to pain in Korea.

Background: The data related to pain and catastrophic health expenditure (CHE) needed to be further explored. This study aims to understand the relationship between pain and CHE. Methods: Using cross-sectional analysis of 4-year data (2015-2018) from the Korea Health Panel, the prevalence of CHE and adjusted odds ratio (AOR) by pain type were confirmed. Results: Among participants (n = 46,597), the prevalence of pain and severe pain were 24.2% and 1.1%, respectively. The use of medical services in emergency rooms, hospitalizations, and outpatients increased in the order of pain-free, pain, and severe pain (P < 0.001). Prevalence of household CHE was 3.3% vs. 11.1% vs. 25.9%, (P < 0.001). The AOR of CHE was 1.5 (95% confidence interval [CI], 1.4-1.7) for pain and 3.1 (95% CI, 2.5-3.9) for severe pain. Household capacity to pay per year was lower and lower in the order of pain-free, pain, and severe pain ($25,094 vs. $17,965 vs. $14,056, P < 0.001). Also, the household out-of-pocket expenditure per year was higher and higher in the order of pain-free, pain, and severe pain ($1,649, $1,870, $2,331, P < 0.001). Conclusions: It can be inferred that pain is one of the mechanisms of poverty. Positivist healthcare policies for the prevention and management of pain should be sought.

Time Series Trend in High BMI and High Out-of-Pocket Expenditure Among Women With Disability.

Health with disability is directly related not only to an individual's quality of life but also to national medical finance. This study focuses on trends in BMI and out-of-pocket (OOP) expenditure of both types of indirect cost exclusion and inclusion. Participants were women with disability (n = 3200) and women without disability (n = 53 082) among adults aged 19 and older from Korea Health Panel from 2009 to 2016. Women with disability had a higher BMI (23.9) than women without disability (22.7), and this time series trend was significant for 8 years (P < .0001). Annual OOP expenditures of both types were higher for women with disability than for women without disability (P < .0001): excluding indirect costs, $518.9 versus $649.4; Including indirect costs, $534.5 versus $681.8. The y-intercept of disability itself and slope of one unit of BMI for both types of annual OOP expenditure is significant (P < 0001): excluding indirect cost, $29.0 and $4.4; including indirect cost, $35.2 versus $4.6. In women with disability, annual OOP expenditure for both types were higher when they were physically inactive (P < .05): excluding indirect cost, $714.1 versus $823.1; including indirect cost, $746.2 versus $880.0. When physical inactivity and overweight and obesity interacted, it increased more than normal weight in dose response manner (P < .05): excluding indirect costs, $799.2 < $800.3 < $886.1; Including indirect costs, $860.2 < $845.9 < $927.5. These results suggest that women with disability are in relatively poor health. It is proposed that inequality of BMI for women with disability can be developed as an agenda from health policy.

A Retro-Aldol Reaction Prompted the Evolvability of a Phosphotransferase System for the Utilization of a Rare Sugar.

The evolution of the bacterial phosphotransferase system (PTS) linked to glycolysis is dependent on the availability of naturally occurring sugars. Although bacteria exhibit sugar specificities based on carbon catabolite repression, the acquisition and evolvability of the cellular sugar preference under conditions that are suboptimal for growth (e.g., environments rich in a rare sugar) are poorly understood. Here, we generated Escherichia coli mutants via a retro-aldol reaction to obtain progeny that can utilize the rare sugar d-tagatose. We detected a minimal set of adaptive mutations in the d-fructose-specific PTS to render E. coli capable of d-tagatose utilization. These E. coli mutant strains lost the tight regulation of both the d-fructose and N-acetyl-galactosamine PTS following deletions in the binding site of the catabolite repressor/activator protein (Cra) upstream from the fruBKA operon and in the agaR gene, encoding the N-acetylgalactosamine (GalNAc) repressor, respectively. Acquired d-tagatose catabolic pathways then underwent fine-tuned adaptation via an additional mutation in 1-phosphofructose kinase to adjust metabolic fluxes. We determined the evolutionary trajectory at the molecular level, providing insights into the mechanism by which enteric bacteria evolved a substrate preference for the rare sugar d-tagatose. Furthermore, the engineered E. coli mutant strain could serve as an in vivo high-throughput screening platform for engineering non-phosphosugar isomerases to produce rare sugars. IMPORTANCE Microorganisms generate energy through glycolysis, which might have preceded a rapid burst of evolution, including the evolution of cellular respiration in the primordial biosphere. However, little is known about the evolvability of cellular sugar preferences. Here, we generated Escherichia coli mutants via a retro-aldol reaction to obtain progeny that can utilize the rare sugar d-tagatose. Consequently, we identified mutational hot spots and determined the evolutionary trajectory at the molecular level. This provided insights into the mechanism by which enteric bacteria evolved substrate preferences for various sugars, accounting for the widespread occurrence of these taxa. Furthermore, the adaptive laboratory evolution-induced cellular chassis could serve as an in vivo high-throughput screening platform for engineering tailor-made non-phosphorylated sugar isomerases to produce low-calorigenic rare sugars showing antidiabetic, antihyperglycemic, and antitumor activities.