National Study of Pain Medicine Access Among Maori and Non-Maori Patients With Lung Cancer in New Zealand.

PURPOSE: Pain is among the most common and consequential symptoms of cancer, particularly in the context of lung cancer. Maori have extremely high rates of lung cancer, and there is evidence that Maori patients with lung cancer are less likely to receive curative treatment and more likely to receive palliative treatment and to wait longer for their treatment than non-Maori New Zealanders. The extent to which Maori patients with lung cancer are also less likely to have access to pain medicines as part of their supportive care remains unclear. METHODS: Using national-level Cancer Registry and linked health records, we describe access to subsidized pain medicines among patients with lung cancer diagnosed over the decade spanning 2007-2016 and compare access between Maori and non-Maori patients. Descriptive and logistic regression methods were used to compare access between ethnic groups. RESULTS: We observed that the majority of patients with lung cancer are accessing some form of pain medicine and there do not appear to be strong differences between Maori and non-Maori in terms of overall access or the type of pain medicine dispensed. However, Maori patients appeared more likely than non-Maori to first access pain medicines within 2 weeks before their death and commensurately less likely to access them more than 24 weeks before death. CONCLUSION: Given the plausibility that there are differences in first access to pain medicines (particularly opioid medicines) among Maori approaching end of life, further investigation of the factors contributing to this disparity is required.

InterRAI assessments: opportunities to recognise need for and implementation of palliative care interventions in the last year of life?

OBJECTIVES: To explore how interRAI assessments could be used to identify opportunities to integrate palliative care into a plan of care. METHODS: A population-based, cross-sectional design using unique identifiers to link deaths with a national interRAI database. Data were analysed using logistic regression models and chi-square tests. RESULTS: A total of 4869 people died over a 12-month period in one district health board area; 50.9% (n = 2478) received one or more interRAI assessments in the year before death. Diagnosis impacted on the type and timing of interRAI assessments and the recognition of end-stage disease. CONCLUSION: People in the last year of life experience frequent interRAI assessments. There are opportunities to identify people who might benefit from a palliative care approach. Future research is needed to understand how interRAI assessors can be supported in the application of assessment items related to palliative care.

Impact of health system protocol on patient qualification for influenza point-of-care testing.

BACKGROUND: Point-of-care testing (POCT) is a service that community pharmacies are implementing to increase patient access to care. Many pharmacies develop protocols with physicians to maximize patient qualification for POCT, while maintaining patient safety. OBJECTIVE: To determine the number of patients seen for influenza in the emergency department (ED) during the 2018-2019 season who would qualify for protocol-driven influenza testing. METHODS: This was a retrospective review of medical records. Patients seen in this 92 bed ED, level III trauma center between October 1, 2018 and May 1, 2019 were included if their age was older than 11 years or younger than 71 years with an influenza-related diagnosis. Patients were excluded if they were pregnant or breastfeeding, were allergic to oseltamivir, were recently diagnosed with pneumonia, or recently received a live influenza vaccine. Patient information collected included: sex, age, height, weight, pulse, blood pressure, respiratory rate, temperature, oxygen saturation, mental status, symptoms, time since onset of symptoms, immune system status, and history of respiratory illness or respiratory disease. These data points were used to determine eligibility for POCT based on a prespecified protocol that included criteria such as vital signs, symptom presentation, and other health conditions. The primary end point was the number of patients eligible for institutional protocol-driven POCT. RESULTS: There were 1955 ED visits with a primary diagnosis of influenza; 451 were eligible for study inclusion, and 49 (11%) qualified for POCT. The most common reason that patients did not qualify was temperature. If required temperature had been removed from the protocol, 155 patients (34%) would have qualified for POCT. CONCLUSION: On the basis of the institutional protocol, a small proportion of patients qualified for POCT. Without the protocol temperature requirement, the number of patients who qualified for POCT would have greatly increased. This study identified opportunities for improvement in the institutional protocol. Future research is needed to reassess the number of patients who qualify once revisions are made.

Alterations in heart-brain interactions under mild stress during a cognitive task are reflected in entropy of heart rate dynamics.

Many people experience mild stress in modern society which raises the need for an improved understanding of psychophysiological responses to stressors. Heart rate variability (HRV) may be associated with a flexible network of intricate neural structures which are dynamically organized to cope with diverse challenges. HRV was obtained in thirty-three healthy participants performing a cognitive task both with and without added stressors. Markers of neural autonomic control and neurovisceral complexity (entropy) were computed from HRV time series. Based on individual anxiety responses to the experimental stressors, two subgroups were identified: anxiety responders and non-responders. While both vagal and entropy markers rose during the cognitive task alone in both subgroups, only entropy decreased when stressors were added and exclusively in anxiety responders. We conclude that entropy may be a promising marker of cognitive tasks and acute mild stress. It brings out a new central question: why is entropy the only marker affected by mild stress? Based on the neurovisceral integration model, we hypothesized that neurophysiological complexity may be altered by mild stress, which is reflected in entropy of the cardiac output signal. The putative role of the amygdala during mild stress, in modulating the complexity of a coordinated neural network linking brain to heart, is discussed.

End of life care for long-term care residents with dementia, chronic illness and cancer: prospective staff survey.

BACKGROUND: Little is known about the quality of end of life care in long-term care (LTC) for residents with different diagnostic trajectories. The aim of this study was to compare symptoms before death in LTC for those with cancer, dementia or chronic illness. METHODS: After-death prospective staff survey of resident deaths with random cluster sampling in 61 representative LTC facilities across New Zealand (3709 beds). Deaths (n = 286) were studied over 3 months in each facility. Standardised questionnaires - Symptom Management (SM-EOLD) and Comfort Assessment in End of life with Dementia (CAD-EOLD) - were administered to staff after the resident's death. RESULTS: Primary diagnoses at the time of death were dementia (49%), chronic illness (30%), cancer (17%), and dementia and cancer (4%). Residents with cancer had more community hospice involvement (30%) than those with chronic illness (12%) or dementia (5%). There was no difference in mean SM-EOLD in the last month of life by diagnosis (cancer 26.9 (8.6), dementia 26.5(8.2), chronic illness 26.9(8.6). Planned contrast analyses of individual items found people with dementia had more pain and those with cancer had less anxiety. There was no difference in mean CAD-EOLD scores in the week before death by diagnosis (total sample 33.7(SD 5.2), dementia 34.4(SD 5.2), chronic illness 33.0(SD 5.1), cancer 33.3(5.1)). Planned contrast analyses showed significantly more physical symptoms for those with dementia and chronic illness in the last month of life than those with cancer. CONCLUSIONS: Overall, symptoms in the last week and month of life did not vary by diagnosis. However, sub-group planned contrast analyses found those with dementia and chronic illness experienced more physical distress during the last weeks and months of life than those with cancer. These results highlight the complex nature of LTC end of life care that requires an integrated gerontology/palliative care approach.

Anaerobic biodegradation of dissolved ethanol in a pilot-scale sand aquifer: Gas phase dynamics.

Groundwater contamination from ethanol (e.g., alternative fuels) can support vigorous biodegradation, with many possible reactions producing dissolved gases. The objective of this study was to improve the understanding of the development and evolution of trapped gas phase changes occurring within an ethanol plume undergoing biodegradation. The experiment performed involved highly detailed spatial and temporal monitoring of gas phase saturations using Time Domain Reflectometry probes embedded in a 2-dimensional (175 cm high × 525 cm long) synthetic aquifer (homogeneous sand tank with horizontal groundwater flow). Ethanol injection immediately promoted gas-producing reactions, including: fermentation, denitrification, sulphate-reduction and iron(III)-reduction, with methanogenesis developing between 69 and 109 days. Substantial in situ increases in trapped gas were observed over ~330 days, with maximum gas saturations reaching 27% of the pore volume. Despite sustained gas production, this maximum was never exceeded, likely due to the onset of gas phase mobilization (i.e., ebullition) upon reaching a buoyancy-capillarity threshold. Reductions in the quasi-saturated hydraulic conductivity, resulting from the gas phase accumulation, were restricted by ebullition to a factor of ≤2; but still appeared to alter the groundwater flow field. Overall, trapped gas saturations exhibited high spatial and temporal variability, including declines within the plume and increases outside of the plume. Influential factors included vertically-shifting ethanol inputs and resultant secondary redox reactions, microbial controls on redox zonation, ebullition, and altered groundwater flows. These observations have implications for the transport of gases and volatile compounds within plumes and above the water table at sites with groundwater contamination from ethanol or other highly degradable organics.

Anaerobic biodegradation of dissolved ethanol in a pilot-scale sand aquifer: Variability in plume (redox) biogeochemistry.

The use of ethanol in alternative fuels has led to contamination of groundwater with high concentrations of this easily biodegradable organic compound. Previous laboratory and field studies have shown vigorous biodegradation of ethanol plumes, with prevalence of reducing conditions and methanogenesis. The objective of this study was to further our understanding of the dynamic biogeochemistry processes, especially dissolved gas production, that may occur in developing and aging plume cores at sites with ethanol or other organic contamination of groundwater. The experiment performed involved highly-detailed spatial and temporal monitoring of ethanol biodegradation in a 2-dimensional (175cm high×525cm long) sand aquifer tank for 330days, with a vertical shift in plume position and increased nutrient inputs occurring at ~Day 100. Rapid onset of fermentation, denitrification, sulphate-reduction and iron(III)-reduction occurred following dissolved ethanol addition, with the eventual widespread development of methanogenesis. The detailed observations also demonstrate a redox zonation that supports the plume fringe concept, secondary reactions resulting from a changing/moving plume, and time lags for the various biodegradation processes. Additional highlights include: i) the highest dissolved H2 concentrations yet reported for groundwater, possibly linked to vigorous fermentation in the absence of common terminal electron-acceptors (i.e., dissolved oxygen, nitrate, and sulphate, and iron(III)-minerals) and methanogenesis; ii) evidence of phosphorus nutrient limitation, which stalled ethanol biodegradation and perhaps delayed the onset of methanogenesis; and iii) the occurrence of dissimilatory nitrate reduction to ammonium, which has not been reported for ethanol biodegradation to date.

Updated New Zealand health system cost estimates from health events by sex, age and proximity to death: further improvements in the age of 'big data'.

AIMS: We aimed to: (i) update previous health system cost estimates (Blakely et al NZMJ 2014;127(1393)) using updated costing data and more refined methods; and (ii) provide context around current developments in the improved networking of health information systems in New Zealand. METHODS: As per our previous work, national health event data were linked for hospitalisations, inpatient procedures, outpatient events, pharmaceuticals, laboratory tests, and primary care consultations for the whole country. For each health event a cost was assigned. Health expenditure by sex and age, and proximity to death (last 6 or 12 months of life), was then calculated. RESULTS: The updated and more accurate method allocated lower amounts of total public health expenditure than the previous work: $6.1, $6.0 and $6.7 billion dollars (inflation-adjusted to 2011 NZ$) in 2007/08, 2008/09 and 2009/10 financial years, respectively. But the latter is still only 52% of total health system costs ($6.7/$12.98 billion). Health system costs for people not within six months of death were similar to the previous work, except for being reduced in the most elderly age groups (range: $495 per person-year in 10-14 year old females; to $5,239 per person-year in 85-89 year old males). Costs in the last six months of life remained highly variable by age group (by a factor of 14 and being maximal at $23,400 or more among 1-4 year olds). The proportion of cumulative health expenditure in the last year of life declined with increasing age of death: eg, 47%, 25%, 13% and 6% for individuals aged 40, 70, 80 and 90 respectively. CONCLUSIONS: Health system costs vary markedly across the life course, and are skewed to the last year of life. This analysis has benefited from quality improvements in cost data and method refinements, but further improvements in coming years are likely. This is particularly so with access to additional data sources, and with the move towards better integration of "big data" in the New Zealand health sector.

Likelihood of residential aged care use in later life: a simple approach to estimation with international comparison.

OBJECTIVES: In New Zealand (NZ), place of death among decedents aged 65+ years has been reported as residential aged care (RAC, 38%), acute hospital (34%) or elsewhere (28%). However, lifetime risk of use of RAC (or nursing homes) is unknown. A simple method of estimation is demonstrated for NZ and Australia, with comparisons to other countries. METHODS: Deaths of RAC residents in acute hospitals were estimated for NZ from four separate studies and added to deaths occurring in RAC, to derive the likelihood of using RAC after age 65 years. Academic and other sources were searched for comparative reports. RESULTS: An estimated 18% of RAC residents died in acute hospital in NZ. When added to those who died in RAC, the proportion using RAC for late-life care was estimated at over 47% (66% if aged 85+ years). Of 12 US reports, the median report was 41%. Elsewhere, Finland was 47%, UK 28%, Australia 34% to 53%, and Germany 22% & 26%. CONCLUSIONS: Simple estimation using existing data demonstrates that RAC in late life is common. IMPLICATIONS: Late-life care services will continue to evolve. Monitoring RAC utilisation is necessary for informed debate about palliative care provision in RAC, use of hospital by RAC residents and for planning and policy setting.

Patterns of entrapped air dissolution in a two-dimensional pilot-scale synthetic aquifer.

Past studies of entrapped air dissolution have focused on one-dimensional laboratory columns. Here the multidimensional nature of entrapped air dissolution was investigated using an indoor tank (180 × 240 × 600 cm(3) ) simulating an unconfined sand aquifer with horizontal flow. Time domain reflectometry (TDR) probes directly measured entrapped air contents, while dissolved gas conditions were monitored with total dissolved gas pressure (PTDG ) probes. Dissolution occurred as a diffuse wedge-shaped front from the inlet downgradient, with preferential dissolution at depth. This pattern was mainly attributed to increased gas solubility, as shown by PTDG measurements. However, compression of entrapped air at greater depths, captured by TDR and leading to lower quasi-saturated hydraulic conductivities and thus greater velocities, also played a small role. Linear propagation of the dissolution front downgradient was observed at each depth, with both TDR and PTDG , with increasing rates with depth (e.g, 4.1 to 5.7× slower at 15 cm vs. 165 cm depth). PTDG values revealed equilibrium with the entrapped gas initially, being higher at greater depth and fluctuating with the barometric pressure, before declining concurrently with entrapped air contents to the lower PTDG of the source water. The observed dissolution pattern has long-term implications for a wide variety of groundwater management issues, from recharge to contaminant transport and remediation strategies, due to the persistence of entrapped air near the water table (potential timescale of years). This study also demonstrated the utility of PTDG probes for simple in situ measurements to detect entrapped air and monitor its dissolution.

Health system costs by sex, age and proximity to death, and implications for estimation of future expenditure.

AIMS: Health expenditure increases with age, but some of this increase is due to costs proximal to death. We used linked health datasets (HealthTracker) to determine health expenditure by proximity to death. We then determined the impact on future health expenditure projections of accounting for proximity to death in costs. METHODS: 2007 to 2009 national health event data were linked for hospitalisations, inpatient procedures, outpatient events, pharmaceuticals, laboratory tests, and primary care consultations. Each event was assigned a cost. Health expenditure by sex, age and whether in last 6 or 12 months of life or not were calculated. Future health expenditure trends were then estimated for the Statistics New Zealand median projection population counts, with 2010-12 mortality rates reducing by 2% per annum into the future. RESULTS: A total of $8.1, $8.8 and $9.2 billion dollars (inflation-adjusted to 2011 NZ$) was allocated to individual health events in HealthTracker in 2007, 2008 and 2009, respectively. Citizen costs for people not within 6 months of death ranged from $498 per person-year (10-14 year old females) to $6900 per person-year (90-94 year old males). Per person-year costs in the last 6 months of life were 10-fold higher on average, being maximal at $30,000 or more among infants and the older elderly (80+ years). Similar patterns were apparent for costs within 12 months of death. For people hypothetically exposed to these 2007-09 health system costs over their full life, the cumulative costs for a person dying at age 70 years was $113,000, and doubled to $223,000 for a person dying at age 90. The proportion of cumulative health expenditure in the last year of life declined with increasing age of death: e.g. 24%, 13% and 10% for someone aged 40, 70 and 90 respectively. Projections of future health system expenditure were overestimated by 2.3% to 3.5% in 2041 when not accounting for proximity to death in costs. CONCLUSIONS: New Zealand is fortunate to have access to rich data on health system costs. The age-specific health system costs per citizen we have calculated can be used in health expenditure projections, for cost-effectiveness analyses, and for considering how public health expenditure is distributed across the life course.

Impact of a mandatory geriatric medicine clerkship on the care of older acute medical patients: a retrospective cohort study.

BACKGROUND: The impact of geriatric medicine educational programs on patient level outcomes, as opposed to educational measures, is not well studied. We aimed to determine whether completion of a mandatory geriatrics rotation changed the clinical behaviors of clerks caring for older patients admitted to a medical clinical teaching unit. METHODS: We reviewed the charts of 132 older (>70y) patients, admitted to one medical clinical teaching unit (CTU) during 2005, and cared for by a clinical clerk, for documented functional assessment, cognitive assessment, recognition of medications that cause confusion, and early removal of indwelling urinary catheters. Performance of these outcomes was compared between clerks who had completed a mandatory 2-week geriatrics rotation immediately before the medical CTU rotation (n = 62) and those who completed geriatrics immediately after (n = 74). Patient outcomes were also measured and compared between groups. RESULTS: Compared to clerks without prior geriatric exposure, clerks with geriatrics exposure were almost 3 times as likely to assess function of their older patients within two days of assuming care (27% vs. 12%, OR: 2.73, 95% CI: 1.12 to 6.66). There were no significant differences in the other clinical behaviors. Patients cared for by geriatrics-exposed clerks were less likely to die or be institutionalized (10% vs. 31%, OR: 0.24, 95% CI: 0.09 to 0.63), and they had shorter lengths of stay by an average of -7.14 days (95% CI: -12.2 to -2.07). Adjustment for baseline differences in age and cognitive impairment did not alter the results. CONCLUSIONS: Clinical clerks who had completed a mandatory geriatrics rotation were more likely to document functional status upon assuming care of their older medical CTU patients, and there was also an association with better clinical outcomes. This highlights the value of including a geriatric medicine rotation as part of the core clerkship curriculum.

Large cell lymphoma: correlation of HIV status and prognosis with differentiation profiles assessed by immunophenotyping.

Diffuse large B cell lymphoma (DLBCL) and plasmablastic lymphoma (PBL) represent aggressive non-Hodgkin lymphomas, particularly in the setting of HIV infection. Since the introduction of highly active antiretroviral therapy (HAART), recent studies have documented improved survival outcome in patients with AIDS-related lymphomas. This study contributes a South African perspective by correlating the HIV status and prognosis of DLBCL and PBL with differentiation profiles assessed by immunophenotyping. Analysis of the morphologic, immunophenotypic and clinicopathologic features of 52 cases of DLBCL and 9 cases of de novo PBL was performed. The overall survival of patients with PBL was poorer than that of DLBCL (logrank p value 0.002). Despite HAART, the overall survival with DLBCL and HIV infection was significantly poorer than HIV negative patients with DLBCL (p value <0.001). Profound immunosuppression was evident in the HIV positive group as the mean CD4 count was 151 cells/mm(3) in DLBCL and 61 cells/mm(3) in PBL. HIV positive patients were significantly younger at presentation with greater likelihood of extranodal lymphoma. When Hans' and Muris' algorithmic stratification of DLBCL were applied, no statistical significance was demonstrated (p values 0.188 and 0.399 respectively). However, when Bcl-2 expression occurred in germinal center-type DLBCL (Hans' defined), improved survival was conferred by the germinal center immunophenotype (p value 0.007). The study demonstrates that DLBCL and PBL have significant potential for aggressive behaviour and poor outcome in the setting of profound immunosuppression due to HIV infection. Further studies are required to assess the effect of targeted-immunotherapy (Rituximab) in combination with recent amendment of the South African national antiretroviral treatment guidelines which has created tremendous potential for improved survival in patients with AIDS-related non-Hodgkin B-cell lymphomas.

Risk equalisation in voluntary health insurance markets: A three country comparison.

The paper summarises the conclusions for health policy from the experience of three countries who have introduced risk equalisation subsidies, in their voluntary health insurance (VHI) markets. The countries chosen are Australia, Ireland and South Africa. All of these countries have developed VHI markets and have progressed towards introducing risk equalisation. The objective of such subsidies is primarily to make VHI affordable while encouraging efficiency in health care production. The paper presents a conceptual framework to understand and compare risk equalisation subsidies in VHI markets. The paper outlines how such subsidies are organised in each of the countries and identifies problems that arise in their implementation. We conclude that the objectives of risk equalisation, in VHI markets are no different to those in countries with mandatory insurance systems. We find that the introduction of risk equalisation subsidies is complex and that countries seeking to introduce risk equalisation in VHI markets must carefully consider how such subsidies advance their overall health policy goals. Furthermore, we conclude that such subsidies must be structured correctly as otherwise incentives exist for risk selection which may threaten affordability and efficiency. Our overall conclusion is that also in voluntary health insurance markets risk equalisation has a role in meeting the related public policy objectives of risk solidarity and affordability, and without it these objectives are severely undermined.

Risk equalisation and voluntary health insurance: The South Africa experience.

South Africa intends implementing major reforms in the financing of healthcare. Free market reforms in private health insurance in the late 1980s have been reversed by the new democratic government since 1994 with the re-introduction of open enrolment, community rating and minimum benefits. A system of national health insurance with income cross-subsidies, risk-adjusted payments and mandatory membership has been envisaged in policy papers since 1994. Subsequent work has seen the design of a Risk Equalisation Fund intended to operate between competing private health insurance funds. The paper outlines the South African health system and describes the risk equalisation formula that has been developed. The risk factors are age, gender, maternity events, numbers with certain chronic diseases and numbers with multiple chronic diseases. The Risk Equalisation Fund has been operating in shadow mode since 2005 with data being collected but no money changing hands. The South African experience of risk equalisation is of wider interest as it demonstrates an attempt to introduce more solidarity into a small but highly competitive private insurance market. The measures taken to combat over-reporting of chronic disease should be useful for countries or funders considering adding chronic disease to their risk equalisation formulae.

The role of risk equalization in moving from voluntary private health insurance to mandatory coverage: the experience in South Africa.

OBJECTIVE: The South African health system has long been characterised by extreme inequalities in the allocation of financial and human resources. Voluntary private health insurance, delivered through medical schemes, accounts for some 60% of total expenditure but serves only the 14.8% of the population with higher incomes. A plan was articulated in 1994 to move to a National Health Insurance system with risk-adjusted payments to competing health funds, income cross-subsidies and mandatory membership for all those in employment, leading over time to universal coverage. This chapter describes the core institutional mechanism envisaged for a National Health Insurance system, the Risk Equalisation Fund (REF). A key issue that has emerged is the appropriate sequencing of the reforms and the impact on workers of possible trajectories is considered. METHODOLOGY: The design and functioning of the REF is described and the impact on competing health insurance funds is illustrated. Using a reference family earning at different income levels, the impact on worker of various trajectories of reform is demonstrated. FINDINGS: Risk equalization is a critical institutional component in moving towards a system of social or national health insurance in competitive markets, but the sequence of its implementation needs to be carefully considered. The adverse impact of risk equalization on low-income workers in the absence of income cross-subsidies and mandatory membership is considerable. IMPLICATIONS FOR POLICY: The South African experience of risk equalization is of interest as it attempts to introduce more solidarity into a small but highly competitive private insurance market. The methodology for considering the impact of reforms provides policymakers and politicians with a clearer understanding of the consequences of reform.

Screening for abdominal aortic aneurysm--a pilot study in six medical schemes.

OBJECTIVE: A pilot study to assess the feasibility and affordability of a targeted screening programme for abdominal aortic aneurysms in a group of employer-based medical schemes. DESIGN: Administrative database review and data extraction. Member enrolment by mail. Analysis using simple descriptive statistics. Review of international experience. OUTCOME MEASURES: Screening uptake and findings, type and cost of interventions recommended by providers. RESULTS: Database review identified 2187 age-eligible subjects (males between 60 and 65 years) who were advised to consult with their doctor/s if they had a history of smoking/and or cardiovascular disease. Two hundred and seven were referred for abdominal ultrasound screening, and aneurysms > or = 3.0 cm were found in 11 (5.3%). Only 1 subject had an aneurysm of sufficient size to justify early surgical intervention, and which resulted in the patient's death. Total cost of this pilot study approached R1 million. Analysis indicated that the sampling rate would have to be increased if such a programme were to be introduced as a routine medical benefit. CONCLUSIONS: International experience has been that screening for abdominal aortic aneurysms reduces morbidity and mortality but at a significant cost. Opinion of the researchers and trustees of the participating medical schemes was that this cost would be beyond the means of schemes at this time. Screening programmes, particularly those that increase health care costs in the early phases by identifying subjects for costly interventions, are unlikely to enjoy support as long as the health funding environment maintains its focus on short-term costs and benefits.

Extraction, isolation, and SDS-PAGE analysis of purified gastric mucin in a patient with Menetrier's disease.

Menetrier's disease is a rare condition characterized by marked proliferation of gastric mucosa with variable mucus secretion and achlorhydria. Although crude mucus secretion and gastric aspirates have been evaluated in this disease for output of dry matter, hexosamine, fucose, protein content, and transforming growth factor alpha activity, we report for the first time the isolation, purification, and gel electrophoresis of mucin from crude mucus scrapings. The fragmentation pattern of mucin in Menetrier's disease demonstrated less large polymeric mucin than the control. There was also a band of approximately 55-65 kd M, on polyacrylamide gel electrophoresis similar to that found in gastric carcinoma or peptic ulcer, but absent in the control specimens.