Journal of Preventive Medicine and Public Health

Volume 36(4); November 2003

Review

Dioxins and Health: Human Exposure Level and Epidemiologic Evidences of Health Effects.: Jae Yeon Jang, Ho Jang Kwon; Korean J Prev Med. 2003;36(4):303-313.

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Abstract PDF: General information is summarized, that is necessary to introduce a scientific assessment of the human health and exposure issue concerning dioxin and dioxin-like compound. Scientific literatures were reviewed to assess the background exposures to the dioxin-like compounds for normal residents. Epidemiologic studies were also reviewed to assess malignant and nonmalignant effects of dioxins. In 1997, the International Agency for Research on Cancer classified 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin (TCDD) as a human carcinogen, primarily based on occupational cohort studies. The US Environmental Protection Agency made the same decision in it's Draft Dioxin Reassessment. Epidemiologic evidences point to a generalized excess of all cancers, without any pronounced excess at specific sites. Reported non-cancer effects included a range of conditions affecting most systems. Among them, chloracne, elevation in gamma glutamyl transferase (GGT), and alterations in reproductive hormones are related to TCDD. Other adverse outcomes, such as lipid concentrations, diabetes, circulatory and heart diseases, immunologic disorders, neurobehavioral effects, and developmental outcomes require further study before their respective relationships to TCDD can be more definitively assessed.; Summary

In Vitro

Exposure Assessment of PCDD/Fs and Monitoring of Health Effects on Workers and Residents near the Waste Incinerators in Korea.: Jong Han Leem, Yun Chul Hong, Kwan Hee Lee, Ho Jang Kwon, Jae Yeon Jang; Korean J Prev Med. 2003;36(4):314-322.

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Abstract PDF: OBJECTIVES
In this study, the exposure status of the hazardous substances from incinerators, such as polychlorinated dibenzo-p-dioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs), were studied, and the relationship between the exposure of these hazardous substances and their heath effects on the workers and residents near municipal solid waste (MSW) incinerators and an industrial incinerator investigated. METHODS: Between July 2001 and June 2002, 13 workers at two MSW incinerators, 16 residents from the area around the two MSW incinerators, 6 residents from the control area, and further 10 residents near an industrial incinerator, estimated to emit higher levels of hazardous substances, were interviewed. Information, including sociodemographic information, personal habits, and work history, detailed gynecologic and other medical history were collected through interviews. Blood samples were also collected from 45 subjects, and analyzed for PCDD/DFs, by high resolution gas chromatography - high resolution mass spectrometry, using the US EPA 1613 method. In addition to the questionnaire survey, urinary concentrations of 8-hydroxydeoxyguanosine (8-OH-dG) and malondialdehyde (MDA) were measured as oxidative injury biomarkers. The urinary concentrations of 8-OH-dG were determined by in vitro ELISA, and the MDA by HPLC, using an adduct with thiobarbituric acid. RESULTS: The PCDD/DFs concentrations in the residents near the industrial incinerator were higher than those in the controls, workers and residents near the MSW incinerators. The average TEQ (Toxic Equivalencies) concentrations of the PCDD/DFs in residents near the industrial incinerator were 53.4pg I-TEQs/g lipid. The estimated daily intakes were within the tolerable daily intake range (1-4 pg I-TEQ/Kg bw/day) suggested by WHO (1997) in only 30% to the people near the industrial incinerator. Animal studies have already shown that even a low body burden of PCDD/DFs, such as 10ng TEQ/kg bw, can cause oxidative damage in laboratory animals. Our study also showed that the same body burden of PCDD/DFs can cause oxidative damage to humans. CONCLUSIONS: The exposures to PCDD/DFs and the oxidative stress of residents near the industrial incinerator, were higher than those in the controls, workers and residents near the MSW incinerators. Proper protection strategies against these hazardous chemicals are needed. Because a lower body burden of PCDD/Fs, such as 10ng TEQ/kg bw, can cause oxidative damage, the tolerable daily intake range should be restrictedly limited to 1pg I-TEQ/kg bw/day.; Summary

Editorial

Health Effect of Dioxin.: Hae Kwan Cheong; Korean J Prev Med. 2003;36(4):323-324.

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Abstract PDF: No abstract available.; Summary

Original Articles

Medical Service Utilization and Trends among Korean Elderly in the Last One Year of Life.: Jee Jeon Yi, Ki Soon Park, Seung Hum Yu, Jeong In Kim, Jae Yong Park, Wang Kun Yoo, Sang Wook Yi; Korean J Prev Med. 2003;36(4):325-331.

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Abstract PDF: OBJECTIVES
To analyze medical service utilization and trends among the elderly in the last year of life. METHOD: The subjects of this study were people that had died at the age sixty-five and above between January 1st and June 30th 2000 The names of the deceased and their dates of death were collected from the data of the funeral-expenses-receivers of the National Health Insurance Corporation (NHIC). This data was merged with that of the individual medical expenses of the NHIC. RESULTS: In the first half of 2000, 84.2% of the funeral-expenses-receivers (53, 063) utilized medical services during the year prior to their death; 51.0% (27, 042) were female and 49.0% (26, 021) male. In the last twelve months of life, the medical fees, the number of days receiving medical services and the number of days receiving medicine were 3, 107, 935 Won, 47.88 and 153.21, respectively, for each person. As the age of the groups increased, the level of medical service utilization decreased; the change was more obvious in female group. The level of medical service utilization during the twelve months prior to death drastically increased around the time of death. CONCLUSIONS: This study, from an analysis of the level of medical service utilization prior to death, shows a concentrated volume of medical services during a certain time period prior to death.; Summary

A Study on the Association between Healthcare Utilization and the Burden of Families Caring for the Elderly in the Last 6 Months of Life.: Jee Jeon Yi, Hee Na Lee, Heechoul Ohrr, Hye Young Jung, Sang Wook Yi; Korean J Prev Med. 2003;36(4):332-338.

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Abstract PDF: OBJECTIVE
To investigate the relationship between medical expenses and the burden of families caring for the elderly in the last 6 months of life, and to evaluate the factors relating to the burden of family caregivers. METHODS: The families of 301 persons older than 65 years, who died between 1 July and 31 December 2001, and were registered in Resident-based- Health Insurance Programs in Seoul, were interviewed. The medical expenses and length of stay among the elderly were collected from Korean Health Insurance Corporations. RESULTS: 31 percents of the elderly had no medical expenses in the last 6 months of life. On average, the objective burden (4.92) was higher than the subjective burden (3.35). Families caring for male elderly had a higher burden. With increasing age at death, the objective burden was significantly increased. The burden on a family seemed to be influenced more by the family income than the property of the elderly. With increasing total health care costs, the objective burden on the family caregivers was significantly increased, but with increasing medical expenses, the subjective burden was significantly decreased. CONCLUSION: An association between healthcare utilization and burden on families was observed. The reason for the decreasing subjective burden when medical expenses were decreased was unclear. Further research will be needed.; Summary

Controlled Clinical Trial

Economic Value of the Sirolimus Eluting Stent (CYPHER(TM)) in Treating Acute Coronary Heart Disease.: Hoo Yeon Lee, Eun cheol Park; Korean J Prev Med. 2003;36(4):339-348.

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Abstract PDF: OBJECTIVE
To quantify the economic value of the Sirolimus Eluting Stent (CYPHER(TM)) in treating acute coronary heart disease (CHD), and to assist in determining an adequate level of reimbursement for CYPHER(TM) in Korea. METHODS: A decision-analytical model, developed by the Belgium Health Economics Disease Management group, was used to investigate the incremental cost-effectiveness of CYPHER(TM) versus conventional stenting. The time horizon was five years. The probabilities for clinical events at each node of the decision model were obtained from the results of large, randomized, controlled clinical trials. The initial care and follow-up direct medical costs were analyzed. The initial costs consisted of those for the initial procedure and hospitalization. The follow-up costs included those for routine follow-up treatments, adverse reactions, revascularization and death. Depending on the perspective of the analysis, the costs were defined as insurance covered or total medical costs (=sum of insurance covered and uncovered medical costs). The cost data were obtained from the administrative data of 449 patients that received conventional stenting from five participating Korean hospitals during June 2002. Sensitivity analyses were performed for discount rates of 3, 5 and 7%. Since the major clinical advantage of CYPHER(TM) over conventional stenting was the reduction in the revascularization rates, the economic value of CYPHER(TM), in relation to the direct medical costs of revascularization, were evaluated. If the incremental cost of CYPHER(TM) per revascularization avoided, compared to conventional stenting, was no higher than that of a revascularization itself, CYPHER(TM) would be considered as being cost-effective. Therefore, the maximum acceptable level for the reimbursement price of CYPHER(TM) making the incremental cost-effectiveness ratio equal to the cost of a revascularization was identified. RESULTS: The average weighted initial insurance covered and total medical costs of conventional stenting were about 6, 275, 000 and 8, 058, 000 Won, respectively. The average weighted sum of the initial and 5-year follow-up insurance covered and total medical costs of conventional stenting were about 13, 659, 000 and 17, 353, 000 Won, respectively. The estimated maximum level of reimbursement price of CYPHER(TM) from the perspectives of the insurer and society were 4, 126, 897 ~ 4, 325, 161 and 4, 939, 939 ~ 5, 078, 781 Won, respectively. CONCLUSION: By evaluating the economic value of CYPHER(TM), as an alternative to conventional stenting, the results of this study are expected to provide a scientific basis for determining the acceptable level of reimbursement for CYPHER(TM).; Summary

Original Articles

Assessment of the Availability of Health Insurance Data for Epidemiologic Study of Childhood Aseptic Meningitis.: Sue Kyung Park, Hae Kwan Cheong, Moran Ki, Young Mo Son, Ho Kim; Korean J Prev Med. 2003;36(4):349-358.

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Abstract PDF: OBJECTIVES
Aseptic meningitis is a major cause of Korean childhood morbidity late spring and early summer. However, the nationwide incidences of the disease have not been reported. This study was conducted to evaluate the availability of National Health Insurance data (NHID) for the study of an epidemiological trend in the surveillance of aseptic meningitis in children. METHODS: All the claims, under A87, A87.8, and A87.9 by ICD-10, among children below 15 years of age, to the National Health Insurance Corporation, between January and December 1998, were extracted. A survey of the medical record of 3, 874 cases from 136 general hospitals was performed. The availability of the NHID was evaluated by the three following methods: 1) The diagnostic accuracy (the positive predictive value = proportion of the confirmed aseptic meningitis among the subjects registered as above disease-codes in NHID) was evaluated through a chart review, and according to age, gender, month and region of disease-occurrence. 2) The distribution of confirmed cases was compared with the distribution of total subjects from the NHID, for subjects in General hospitals, or the subjects surveyed. 3) The proportion of confirmed CSF test was confirmed, and the relating factor, which was the difference in CSF-test rate, analyzed. RESULTS: Among 3, 874 cases, CSF examinations were performed on 1, 845 (47.6%), and the CSF-test rates were different according to the medical utility (admission vs. OPD visit) and the severity of the symptoms and signs. The diagnostic accuracy for aseptic meningitis, and during the epidemic (May-Aug) and sporadic (Sept-Apr) periods, were 85.0 (1, 568/1, 845), 86.0 (1, 239/1, 440) and 81.2% (329/405), respectively. The distributions by age, sex, month or period (epidemic/sporadic) and region, in the confirmed cases, were similar to those in the NHID, in both the subjects at General hospitals and in those surveyed, to within +/-7%. CONCLUSIONS: In this paper, the NHID for the subjects registered with an aseptic meningitis disease-code might be available for an epidemiological study on the incidence-estimation of childhood aseptic meningitis, as the NHID could include both the probable and definite cases. On the basis of this result, further studies of time-series and secular trend analyses, using the NHID, will be performed.; Summary

Factors Affecting the Diffusion of Health Center Information System.: Jin Yong Lee, Young Gyoung Do, Jung Gyu Lee, Gi Dong Park, Chang Yup Kim, Yong Ik Kim; Korean J Prev Med. 2003;36(4):359-366.

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Abstract PDF: OBJECTIVES
This study was conducted to review the diffusion process and factors affecting the adoption of the Health Center Information System (HIS). METHODS: Data were collected from POSDATA (private company), MOHW, other Ministries and local governments. To specify the date of adoption, supplementary information was collected from 40 health centers. The following three kinds of factors were analyzed. Internal factors included type, size, and innovativeness of health centers. Community factors were composed of population size, economic status, and level of education. Organizational environmental factors consisted of information score of the municipalities, financial support of the from central government, and the neighborhoodness of innovator health centers. RESULTS: All health centers in the metropolitan cities of Seoul, Gwangju and Jeju adopted the HIS. The laggards were those in the metropolitan cities of Busan (18.8%), Incheon (20.0%) and Daejun (20.0%), and cities with population more than 300, 000 (54.8%) and counties with health center hospitals (47.1%). Financially supported rural health centers adopted the HIS more rapidly than those not supported. The factors identified as being statistically significant (p< 0.05), from a univariate analysis by Kaplan-Meier method, were: (1) internal factors of the type, size and innovativeness of health centers; (2) community factors of population size and economic status; (3) organizational environmental factors of the central government financial support and the neighborhoodness of innovator health centers. A multivariate analysis, using a Cox proportional hazard method, proved the innovativeness of health centers, central government financial support and the neighborhoodness of innovator health centers, were statistically significant (p< 0.05). CONCLUSIONS: The innovativeness of health centers, financial support from central government and the neighborhoodness of innovator health centers, rather than community factors related to regional socioeconomic status, affected the adoption of the HIS in health centers. Further in-depth studies, modifying the MOHW's strategy to propagate the HIS to the laggard health centers, are recommended.; Summary

A Study on the Association Between Ginseng Intake and Incidences of Cancer: Kangwha Cohort Study.: Joo Sun Byun, Heechoul Ohrr, Sang Wook Yi, Jae Suk Hong, Tae Yong Sohn; Korean J Prev Med. 2003;36(4):367-372.

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Abstract PDF: OBJECTIVES
There are many concerns about ginseng as a cancer chemopreventive substance, but there have been few epidemiological studies on ginseng. This study sought to examine the relationships between ginseng intake and cancer incidence in the Kangwha cohort. METHODS: Between March 1985 and December 1999, 2697 males, aged 55 or over, as of 1985, were followed up for their cancer incidence. The cancer incidence rate, standardized incidence ratio and risk ratios were calculated according to ginseng intake. A Cox proportional hazard model was used to adjust for age at entry, smoking, alcohol intake, hypertension, and body mass index. RESULTS & CONCLUSIONS: The ginseng intake group had the same cancer (C00-C97) incidences (Standardized Incidence Ratio: SIR=1.11, 95% Confidence Interval = 0.97-1.27) and the same risk ratio (RR=1.09, 95% Confidence Interval = 0.85-1.41) as the no-intake group. Analyzing the subjects that had followed up from 1990, however, the ginseng intake group had lower cancer incidences at all sites (RR = 0.79, 95% Confidence Interval = 0.58-1.09). This was a cohort study to try and evaluate the association between ginseng intake and the incidences of cancer. The results of this study provide no clear conclusions on the cancer preventive effects of ginseng. Therefore, further study is needed in the future.; Summary

Multicenter Study

Assessment of DNA Viability in Long Term-Stored Buffy Coat Species for the Korean Multicenter Cancer Cohort.: Mihi Yang, Jihyun Yoo, Cheong Sik Kim, Aesun Shin, Daehee Kang, Soung Hoon Chang, Sue Kyung Park, Hai Rim Shin, Keun Young Yoo; Korean J Prev Med. 2003;36(4):373-376.

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Abstract PDF: OBJECTIVES
Peripheral blood-buffy coat fractions (N = 14, 956) have been stored at -70degrees C in the headquarter of the Korean Multicenter Cancer Cohort (KMCC), since 1993. To study the future molecular etiology of cancers using specimens of the cohort, properly stored specimens are necessary. Therefore, the DNA-viability of the buffy coat samples was investigated. METHODS: Buffy coat fraction samples were randomly selected from various collection areas and years (N = 100). The DNA viability was evaluate from the UV-absorbent ratios at 260/280nm and the PCR for beta-globin was performed with genomic DNA isolated from the buffy coat. RESULTS: PCR products were obtained from 85 and 98% of the C and H area-samples, respectively, using 50 or 100mul of the buffy coat. There were significant differences in the yields of the PCR-amplifications from the C and H areas (p < 0.05), which was due to differences in the homogenization of the buffy coat fractions available as aliquots. The PCR-products were obtained from all of the samples (N = 7) stored at the C area-local center, but the other aliquots stored at the headquarter were not PCR-amplified. Therefore, the PCR products in almost all the samples, even including the DNA-degraded samples, were obtained. In addition, an improvement in the DNA isolation, i.e. approx. 1.6 fold, was found after using extra RBC lysis buffer. CONCLUSIONS: PCR products for beta-globin were obtained from nearly all of the samples. The regional differences in the PCR amplifications were thought to have originated from the different sample-preparation and homogenization performance. Therefore, the long term-stored buffy coat species at the KMCC can be used for future molecular studies.; Summary

Original Articles

Predictors of Stage of Change for Smoking Cessation among Adolescents based on the Transtheoretical Model.: Namhee Park, Jungsoon Kim, Ihnsook Jeong, Byungchul Chun; Korean J Prev Med. 2003;36(4):377-382.

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Abstract PDF: OBJECTIVES
The purpose of this study was to investigate the predictor associated transitions with each stage of smoking cessation based on the Transtheoretical Model, and to provide basic data for smoking cessation programs for adolescents. METHODS: The participants were 297 current and former smokers, obtained from stratified random sampling of 2nd graders from 127 high schools in B cities. The data were collected between April 6th and 16th 2002, using a structured self-report questionnaire, and analyzed using a multiple logistic regression, with the SPSS program for Windows (Version 10.0). RESULTS: The predictors of transition from precontemplation to contemplation were consciousness raising (OR=1.22, 95% CI: 1.07-1.40), coping pros (OR=.84, 95% CI: .70-1.00) and attitude of parents to smoking (OR=2.97, 95% CI: 94-9.24). The predictors of transition from contemplation to preparation were helping relationships (OR=.83, 95% CI: 72-.96), self-liberation (OR=1.15, 95% CI: 99-1.33) and nicotine dependence (OR=.76, 95% CI: 56-1.03). The only predictor of transition from preparation to action was the social pros (OR=.66, 95% CI: .57-.82). The predictors of transition from action to maintenance were self-reevaluation (OR=.81, 95% CI: .71-.92) and negative affective situation (OR=.85, 95% CI: .72-1.00). CONCLUSIONS: Adequate examination on the factors for predicting the transitional stages of change for smoking cessation in Koreans are presented in this study. The results of this study will become the pillar of smoking cessation planning and application programs.; Summary

Type of Alcoholic Beverage and High Risk Drinking for Acute Harm.: Woojin Chung, Taiwoo Yoo, Sunmi Lee; Korean J Prev Med. 2003;36(4):383-389.

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Abstract PDF: OBJECTIVE
Studies have suggested that beer is associated with a high risk of mortality and morbidity. The purpose of this study was to investigate how types of alcoholic beverage are related to high risk acute harm. METHODS: Data from the 1997 Korea's Behavioral Risk Factor Surveillance System Survey, collected through telephone questionings, were analyzed based on multi-stage stratified random sampling (N=1, 045). Among those who had drunk at least one type of alcoholic beverage in the last month, one episode where the drinker had consumed the highest level of ethanol was selected, and the alcohol consumption per drinking day categorized into four risk levels of short-term, 'acute' harm, according to the WHO guidelines. Employing ordered logistic regression analyses, as the explanatory variables, types of alcoholic beverage, with and without socioeconomic characteristics, were considered. RESULTS: Spirits and soju were more than ten and three times, respectively, more likely than beer, while makkolli and wine were almost as likely as beer, to involve high risk drinking, irrespective of controlling for the socioeconomic characteristics. CONCLUSIONS: Unlike most Western countries, in Korea, beer, rather than spirits or soju, is generally less likely to be associated with high risk drinking for acute harm. The influence of beverage types on high risk drinking for acute harm appears to vary between countries.; Summary

A Study on the Related Factors with Internet Addiction of the 11th Grade Students in an Urban Area.: Moo Sik Lee, Keon Yeop Kim, Kyung Jae Ko, Hyo Jin Lee, Wook Nam, Eun Young Kim, Jee Young Hong, Bak Ju Na; Korean J Prev Med. 2003;36(4):390-398.

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Abstract PDF: OBJECTIVES
To evaluate the degree of adolescent internet addiction, and investigate its relationship to the general characteristics, internet environments, and contents, especially the stress measured by the psychosocial wellbeing index-short form (PWI-SF). METHODS: The data was obtained from self-administered questionnaires from 886 11th grade urban area students. The questionnaires consisted of general characteristics, internet user's environments, frequencies by internet contents, internet addiction test and PWI-SF. RESULTS: The possible rate of internet use at home was 95.1%, and the area of most internet use was the home. The frequencies of internet game and porno site use were higher in males, with web searching and community uses higher in females. The total mean of internet addiction score was 56.8, and was higher for male than for female students. From multiple regression, as analyzed by the internet addiction score as a dependent variable, on-line friends, internet use times, years of internet use, frequencies of internet game & porno site use, and PWI-SF scores were significant in male. Internet use times, the frequencies of internet game, chatting, community use, and PWI-SF score were significant in female. Four PWI-SF subscales (social role & self reliability, depression, general health & vitality, and sleep disturbance & anxiety) and internet addiction were significantly correlated in both male and female students, with depression having the most correlation. CONCLUSION: The results of this study suggest that intervention should be provided to prevent internet addiction, especially for coping with stress in Korean teenage students.; Summary

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