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Fifty-six percent of women with T. vaginalis infection in our study were symptomatic and the symptoms occurred independently of the presence of TVV in the protozoon. In vitro studies have shown that TVVs are sensed by the human epithelial cells via Toll-like receptor 3, triggering Interferon Regulating Factor − 3, interferon type I and pro-inflammatory cascades previously implicated in preterm birth and HIV-1 susceptibility . While treatment with metronidazole generally eliminates T. vaginalis, this may aggravate T. vaginalis-associated inflammation caused by the release of TVV by stressed or dying parasites . Additionally, TVVs upregulate levels of phenotypically variable immunogen mRNA P270 of T. vaginalis , while also playing a role in T. vaginalis protein composition and its growth kinetics .
|
study
| 100.0 |
Our study was limited by the small number of isolates, which rendered it difficult to investigate the implication of TVV carriage on clinical signs and symptoms. Despite the low number of T. vaginalis isolates, the presence of all four types of TVVs in our isolates, in addition to the five actin genotypes, demonstrates there is notable genetic diversity of T. vaginalis isolated from pregnant women in Kilifi, Kenya. Isolates of the most prevalent actin genotype E lacked TVVs; further studies with higher number of strains should be conducted in order to corroborate these results. The actin gene should be considered as a potential genetic marker for molecular epidemiology and genotypic traits of T. vaginalis.
|
study
| 100.0 |
Additional file 1: Table S1.Genotype, number and position of restriction sites using HindII, MseI and RsaI restriction enzymes for actin sequences retrieved from GenBank. (DOCX 15 kb) Additional file 2: Figure S1. Alignment of the T. vaginalis actin gene nucleotide sequences retrieved from GenBank and those of from the clinical T. vaginalis isolates of the present study. (PDF 1746 kb)
|
study
| 100.0 |
Cancer is the second leading cause of death in the world, with over 8 million fatalities annually . Despite advances in both prevention and treatment options, the cancer burden continues to rise globally, fuelled by an ageing population and increasing lifestyle-related risk factors . The prevalence of cancer in the Middle East is high and growing . The World Health Organization (WHO) reports that within the next 15 years, the Middle East is likely to experience the highest increase in cancer incidence among WHO regions, with predicted increases as high as 100–180% [3, 4]. Recent improvements in multi-regimen modalities have resulted in significant increases in disease-free survival rates [5, 6], but do not address the supportive care needs of oncology patients. There is a large body of literature documenting that cancer patients are at risk for adverse physical, psychological, spiritual and social problems throughout the course of their diagnosis and treatment . Physical complaints, including illness and disability, psychological concerns manifested as fear of pain or death and social issues, such as family dynamics, all affect cancer patients, with levels of accompanying distress that vary from patient to patient . The distress can interfere substantially with comfort, quality of life and the ability to make suitable decisions or to adhere to treatment . Negative patient and family experiences can also be a reflection of health care delivery systems that do not account for patient and family needs . Patient needs affect all types and stages of cancer . Supportive care needs also differ across countries and cultures . Among ethnically diverse groups of patients, culture has been shown to influence perceptions and coping mechanisms related to disease management . Therefore, cultural beliefs and values can serve as important determinants of clinical outcomes following cancer diagnosis and treatment .
|
review
| 99.9 |
There is a paucity of published data and limited understanding of the unmet needs of cancer patients in the Middle East, particularly in the Gulf Cooperation Council (GCC) countries, consisting of Kuwait, Qatar, Oman, Saudi Arabia, Bahrain and the United Arab Emirates (UAE). Identifying and addressing these unmet needs can lead to many positive patient outcomes, including better ability to cope with disease symptoms and treatment side-effects, improved physician–patient communication and better adherence to treatment regimens [7, 15]. The purpose of this study is to assess the unmet needs of cancer patients in the UAE, with the goal of improving the supportive care services for these patients and, thereby, positively impacting their overall quality of life .
|
study
| 99.94 |
A cross-sectional survey was conducted by a bilingual (Arabic and English) physician and, nurse researcher between December 2014 and December 2016 at a tertiary care, Joint Commission International accredited hospital and a regional oncology referral centre. The validated short form of the SCNS-SF34 was used for the study, primarily because of its feasibility and ease of use and coverage of many of the major domains of unmet needs . The SCNS-SF34 assesses cancer-specific perceived needs across five analytically derived domains: psychological (10 items), health system information (11 items), patient care and support (5 items), physical and daily living (5 items) and sexuality (3 items) . The SCNS-SF34 was provided by Dr. Allison Boyes (University of Newcastle upon Tyne, Australia) . Prior to study commencement, the SCNS-SF34 was translated by a certified legal translator into Arabic, the preferred local language of the patients, and then, back translated into English to ensure the quality of the translation and to ensure that the structure, content and intent of the survey items did not alter during translation. Both the English (n = 14) and Arabic (n = 17) versions were pretested for reliability in the local setting using 31 patients from the oncology outpatient clinic.
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study
| 100.0 |
Participating subjects were ambulatory patients diagnosed with cancer who presented to the oncology outpatient clinics. Potential participants were randomly selected using the patient appointment booking module of Malaffi, the hospital information system. Inclusion criteria included men or women aged 18–75 with a confirmed new or recurrent cancer diagnosis, who were informed of the cancer diagnosis and were capable of providing informed consent and completing the survey questionnaire, based on the European Cooperative Oncology Group (ECOG) status (0–3) . Patient participants unable to meet the ECOG status, patients with mental or cognitive disorders and those unable to understand or unwilling to provide informed consent were excluded from the study. Respondents were asked to indicate their level of need for help during the last month for each item on the survey on a 5-point Likert scale, with the following response options: 1 = no need, not applicable; 2 = no need, satisfied; 3 = low need; 4 = moderate need and 5 = high need . Survey participants who selected a score of 4 or 5 indicated moderate or high unmet needs that required assistance . Additional information, if required, was obtained from the patient’s medical record and the hospital’s cancer registry. Written consents were obtained from the respondents.
|
study
| 100.0 |
Data were analysed using SPSS Statistical Software Version 20 (SPSS Inc. Chicago, USA). The domains were identified as reported elsewhere . The widely used principal component analysis (PCA) was used as the extraction method to undertake exploratory factor analysis; and varimax rotation was used to rotate the factors to better fit the data . Convergent validity to assess if the survey items converged to measure a construct was also conducted using the correlation coefficient matrix method . The percentage of total variance by each factor was calculated and pattern matrix was used to identify the domains. Kiaser–Meyer–Olkin (KMO) sampling adequacy and Bartlett’s tests (to assess the strength of the relationship among the variables) were also applied to the construct . The reliability of the inventory and its subscales were tabulated using Cronbach’s alpha. In addition to descriptive statistics, the Chi-square test was adopted to assess the association between variables. Participant responses to each of the items were tabulated as mean ± SEM. Comparison of means, when required, was accomplished using MedCalc software . The study was approved by the regional research ethics committee (AAMDHREC 12/55).
|
study
| 100.0 |
Approximately 300 patients with either a new cancer diagnosis or a diagnosed recurrence are treated at these oncology outpatient clinics every year. Based on our previous experience of a fully completed survey return rate of 80% in this population , 34 more participants were added to the original sample size of 169 (confidence level 95%, confidence interval 5%), obtaining a minimum sample size of 203 patient participants for the study. Two hundred and ten completed questionnaires were returned out of 268 administered (78.3% response rate). The demographics of the patient participants are given in Table 1. The majority of the survey respondents were female (69%, n = 144), married (76%, n = 159), with college-level education (54%, n =113).
|
study
| 100.0 |
Comparison of the five analytically derived domains indicated a significantly high psychological need (3.63 ± 0.023), followed by physical and daily living needs (3.04 ± 0.029, p < 0.001), health system information needs (3.03 ± 0.02, p < 0.001), patient care and support (2.95 ± 0.24, p < 0.001), with low sexuality needs (1.79 ± 0.08, p < 0.001) (Figure 1). Five out of 10 items (50%) from the psychological domain constituted the 10 most prevalent unmet moderate or high needs of oncology patients in the UAE, including concerns regarding an uncertain future (80%) and feelings about death and dying (77.1%) (Table 2). Moderate or high feelings of lack of energy and tiredness (75.2%), as well as pain affecting their physical and daily living activities (74.8%), were prevalent in more than three-quarters of the participants. Needs related to sexuality, such as receiving information about sexual relationships (16.7%) and changes in sexual feelings (9.5%), scored low (no need or satisfied) for almost 85% of the patient population surveyed, data not shown.
|
study
| 100.0 |
Table 3 reports gender differences in participant responses. Gender correlated strongly with sexuality (changes in sexual feelings), with men expressing higher unmet need than women (r = 0.901, p < 0.001). Women had significantly higher psychological unmet needs of ‘feeling down or depressed’ (r = 0.42, p < 0.001) and ‘feelings of sadness’ (r = 0.26, p < 0.001), as compared with male respondents. The need to be informed about cancer directly from the doctor, rather than a relative, was also moderately high among women (r = 0.37, p < 0.001). Physical limitation, such as ‘feeling unwell a lot of time’, positively correlated (r = 0.28, p < 0.001) with the unmet needs for women. ‘Uncertainity about the future’ (psychological) was directly correlated with patient age (r = 0.14, p < 0.05 2-tailed significance, data not shown).
|
study
| 100.0 |
Cultural differences in responses amongst the patient respondents are givenn in Table 4. UAE nationals reported higher unmet needs in the health system information domain. No other statistically significant differences in reports of unmet supportive care needs were noted between UAE nationals and non-nationals, or between Arabs and non-Arabs (data not shown).
|
study
| 99.94 |
The consistency of the SCNS-SF-A was measured using the PCA, obtaining a KMO value of 0.88, reaching statistical significance. Bartlett’s test of sphericity was significant (0.000). The PCA revealed the presence of a component with an eigen value of 14.9, explaining 81.2% of total variance. Correlation coefficient indicating relationship between the items is given in Table 5. Cronbach’s α reliability assessment of each of the four domains ranged between 0.73 and 0.84 (Table 5). The overall Cronbach’s α reliability score for all 34 items for the final construct was high at 0.79.
|
study
| 100.0 |
Wellbeing in cancer patients can be considered a balance between two sets of factors: the stress and burden resulting from the cancer experience and the resources available for coping and mitigating stress and burden [10, 11]. Our study demonstrates that cancer patients in the UAE experience a wide range of unmet supportive needs, primarily related to psychological needs. Amongst the critical top 10 unmet needs of the patients surveyed, 50% were psychological in nature, with women expressing significantly higher psychological needs than men. This finding suggests that the improvement of mental health services for cancer patients is an urgent priority. Proactive encouragement and recruitment of female cancer patients into counselling services can help mitigate some of their needs.
|
study
| 99.94 |
In addition, the high prevalence of physical symptoms, including lack of energy, tiredness and pain limiting physical and daily living, is quite concerning. This highlights the need to focus on early and adequate pain management and physical rehabilitation as important components of cancer care. Oncology units in the UAE should consider inculcating these specialities into multidisciplinary cancer care teams. It has also been reported that patients have several misconceptions regarding pain, specifically that increasing pain signifies disease progression, medicine to control pain may weaken the immune system and pain is inevitable for cancer patients . These beliefs identify a need for cancer support groups to address misinformation and help manage patient needs. A large body of literature demonstrates that participation in cancer support groups improves patients’ quality of life and wellbeing [22, 23]. As such, the development of this service at oncology centers throughout the UAE can serve as viable channels of information and help to meet several of the psychological needs of cancer patients.
|
review
| 79.0 |
Furthermore, the unmet need of cancer patients to be informed about their diagnostic tests in a timely manner and to be provided an explanation about their test results indicate that system changes are required. In the UAE, it is common practice to send diagnostic specimens overseas for genetic and mutational analysis, leading to delays in reporting results. The inclusion of genetic counsellors as part of the multidisciplinary care teams for cancer management can provide accurate, timely information and help alleviate some patient fears during the diagnostic process. The finding that women were more concerned about receiving test results directly from the doctor, instead of a family member, is not surprising given that the UAE, as much of the Arab world, is a patriarchal society where physicians often receive consent from, and discuss results with, male family members instead of female patients. It is important that cancer care health professionals understand the need for all patients to be included in treatment discussions. Actively involving women in all treatment decisions will help to alleviate this concern. Also, the addition of social workers into cancer care teams to directly address female patient needs may help resolve potential family dynamic issues.
|
other
| 99.56 |
Interestingly, sexuality scored low as an unmet need for cancer patients in our study, although men expressed higher unmet need for sexuality as compared to women (r =0.901, p < 0.001). This is consistent with previous studies demonstrating that patterns of unmet supportive care needs differ across cultures and health care services among Caucasians, Japanese and Chinese [24, 25, 26]. Previous studies, based on Hong Kong Chinese women with breast cancer, also showed similar low unmet needs related to sexuality [12, 13, 18, 21, 26]. In the UAE, it is not standard practice to routinely assess sexual wellbeing in cancer and palliative care patients, as it is often not a presenting symptom. Also, it is possible that the reported low sexual needs were due to an unwillingness of the patient to discuss sexual concerns. Routinely addressing sexual issues as part of cancer treatment may overcome some of these cultural barriers and ensure that this aspect of patient care needs is met.
|
study
| 99.94 |
The study did not reveal significant cultural differences in unmet supportive care needs among the oncology patients in the UAE, perhaps because most respondents were from in and around the Arab world. As all patients were residents of the UAE, it is also possible that respondents had already assimilated to UAE culture.
|
study
| 99.94 |
The strengths of this study include the high response rate and participation of multi-ethnic patients. We also attempted to minimise the effect of social desirability response bias by assuring respondent confidentiality. Our results, however, should be viewed in light of some limitations. First, the cross-sectional study design provides correlation, but not causal inference. Patients from only two institutions were surveyed; however, both participating hospitals have large oncology units and one is the regional referral centre for the UAE and neighbouring countries. Also, most patient participants had breast or gynaecologic malignancies. Perspectives of patients with other malignancies, including gastrointestinal cancers, are important. Finally, inherent to any self-report of complex issues, such as quality of life, there are influencing factors that may not have been fully addressed in this study, including family/caregiver and social support, spirituality and patient individual personality. Notwithstanding these limitations, to our knowledge, this is the first study in the region that has assessed the supportive care needs of cancer patients and provides valuable information to improve patient care. Identifying and understanding cancer patient perspectives is a first step in the development of hospital and community services to meet their needs. Future studies focusing on the implementation of integrated multidimensional approaches to cancer support services are needed to help improve the quality of UAE cancer patients’ and families’ lives.
|
study
| 99.94 |
As the cancer rates climb in the UAE, it is important to fully understand and meet the needs of oncology patients. Our study has identified several opportunities to improve the care and support services available. Oncology centres in the UAE should develop an integrated, multifaceted approach to identify and meet the supportive care needs of cancer patients. The improvement of mental health services for oncology patients, development of multidisciplinary cancer care teams, introduction of cancer support groups and fully engaging women in all treatment discussions and decisions, are all feasible and easy to implement interventions that can significantly improve patient care and wellbeing. As the UAE is a multi-ethnic and multicultural society, the findings of this study may prove to be useful in addressing the needs of cancer patients in the pan Arab region.
|
study
| 50.06 |
Access to abortion care in the United States (US) is limited by the availability of abortion providers—the number of providers, their geographic distribution, and their willingness to accept insurance. The number of abortion providers in the country has declined in recent years; the most recent census of abortion providers estimated a total of 1720 in the US in 2011, down 4% in just three years from 1793 in 2008 and down 5% from 1819 in 2000 . The geographic distribution of providers is not uniform; most providers are concentrated in major cities and not easily accessed by would-be patients in more rural areas. While among all US counties in 2011, 89% had no abortion provider (and were home to 38% of US women aged 15–44), rural counties were less likely to have a provider: 97% of rural counties had no provider compared to 69% of urban counties [1, 2]. In California, 45% of counties (home to 5% of CA women 15–44) had no abortion provider .
|
study
| 99.25 |
Existing studies have examined geographic accessibility to abortion, though to our knowledge no study has examined distances traveled specifically by those using Medicaid funds, or more broadly, by low-income women who may be most burdened by additional travel costs and time. Average distance traveled for abortion has been estimated at the national and regional levels for the general population of abortion patients in the United States , and distance estimates exist at the state level for Louisiana , New York and Texas [6, 7]. Studies have also used estimates by clinic managers and other key informants at facilities to calculate the proportion of patients traveling distances greater than 50 miles to reach the abortion facility [8, 9]. Estimates of the percent of women traveling greater than 50 miles have changed little over time; in 2005 27% of abortion patients traveled >50 miles, in 2001, 1997, and 1993 an estimated 24% traveled >50 miles [8–10]. A nationally representative survey of abortion patients in 2008 estimated that women traveled an average of 30 miles for abortion services, with a median of 15 miles and that 67% traveled less than 25 miles, 16% 25–29 miles, 11% 50–100 miles and 6% more than 100 miles for care . Controlling for other factors, this study found that rural women and women obtaining second trimester abortions were more likely to travel greater distances, while women of color were less likely to travel long distances than non-Hispanic white women.
|
study
| 99.94 |
Distance traveled to abortion has been studied in several other countries as well, and these studies suggest that rural and minority groups travel furthest to obtain abortion care. Studies in Canada found, as in the US, geographic disparities in abortion access due to clustering of provision in urban centers . One national study found that 18% of women traveled more than 100 km (62 miles) to reach an abortion clinic and that younger woman and Aboriginal women traveled significantly further for services than older and white women . A review of studies examining barriers to abortion access in Australia found that interstate travel for abortion was common, rural access to abortion was limited, and that greater travel distances were associated with greater costs . In New Zealand, a study of access to first trimester abortion found that women in regions without an abortion provider had to travel on average 137 miles each way to reach abortion services, and that regions without a provider had higher than average native (Maori) populations .
|
review
| 99.9 |
Not all abortion providers offer all types of abortion care; compared to first trimester abortion providers, second trimester providers are relatively scarce. Almost all (95%) abortion providers offer abortion care at 8 weeks since last menstrual period (LMP); however, this drops to 61% offering care past 12 weeks LMP, and 16% offering care past 24 weeks LMP . Consequently, women who do not access a provider in their first trimester may find it more difficult to find a provider in the second trimester, and increasingly so as time passes [16–18]. Previous studies have shown that women presenting for abortions in the second trimester travel longer distances than women in the first trimester [19, 20]. This is clinically problematic because increased gestation is associated with greater risk of morbidity [21, 22] and mortality [23, 24]. For example, the rate of major adverse events after a first trimester abortion is 0.16%, and after second trimester or later abortions is 0.41% . While these rates are already extremely low, they could be further reduced if women seeking abortion could obtain care as early as desired. The distance a patient must travel to reach a provider may affect her ability to receive timely care, or any care at all.
|
study
| 89.5 |
Currently, public funding for abortion care is available in only 17 states . California is one of these states; California’s Medicaid program, Medi-Cal, covers about half of California abortions [1, 27]. However, public funding for abortion does not guarantee that publically funded abortions will be accessible. California-based studies have found that difficulty getting Medi-Cal to pay for abortion contributes to delays in obtaining abortion, pushing women into the second trimester. These difficulties include women’s lack of knowledge about available coverage, difficulty negotiating the Medi-Cal application process and difficulty locating an abortion provider that accepts Medi-Cal payment [16, 18]. Given these barriers, it is likely that many women who are eligible for Medi-Cal-coverage for their abortions will choose to instead pay out-of-pocket if they can. In a multi-state study of barriers to Medicaid acceptance for abortion, providers cited low Medicaid abortion reimbursement rates as the primary barrier to accepting Medicaid . Complex billing procedures and slow reimbursement times were also frequently mentioned. A 2006 examination of Medi-Cal acceptance among abortion providers publically advertising in Yellow Pages found that only 53% accepted Medi-Cal through the first trimester, 20% accepted Medi-Cal up to 20 weeks gestation, and 4% accepted Medi-Cal past 21 weeks . Though surveys identified 512 total abortion providing facilities in California in 2011 , it is not known how many of these facilities accepted Medi-Cal payment.
|
study
| 99.9 |
A simple count of abortion providers in each state does not distinguish between types of providers in terms of gestational limits, eligible patients, or payment types accepted. Hospitals are less likely to accept patients other than for medical indications or high-risk conditions which could not be managed in typical outpatient settings, and obstetrician/gynecologist or family physician private practice offices are unlikely to accept patients outside their own established patient base . Practices differ in gestational limits, types of procedures, availability and open hours, costs and payment types accepted, and protocols, all of which may affect which abortion provider a woman is actually able to access.
|
other
| 99.9 |
Though distance to care is known to affect abortion access, a comparison of abortion rates by geography may be complicated by cultural differences in rural populations, such as fertility preferences, attitudes towards abortion, and abortion stigma, which may cause differences in the utilization of abortion beyond those caused by increased distance alone . One of the earliest studies of distance traveled for abortion post Roe v. Wade found that the greater the distance from an abortion clinic, the lower the abortion rate, but acknowledged that lower abortion rates may be a function of women in more rural areas far from abortion clinics preferring not to terminate a pregnancy as well as a lack of knowledge of the availability and location of abortion providers . Rural populations are less likely to support abortion under a range of circumstances than their urban counterparts and studies have shown higher fertility rates paired with lower abortion rates among rural women compared to urban women in specific contexts . Although rural women are underrepresented among abortion patients , the reasons for this are not well understood.
|
review
| 99.7 |
In this study we examine the distances women travel for Medi-Cal-covered abortion care in California, the factors associated with traveling longer distances, and the facilities offering abortion care to Medi-Cal beneficiaries using a unique dataset on abortions covered by California’s state Medicaid program in 2011 and 2012.
|
study
| 99.7 |
We conducted a retrospective observational cohort study of abortion claims data in the California Medicaid program (Medi-Cal). We obtained data on all abortions covered by the fee-for-service (FFS) Medi-Cal program in 2011 and 2012 from California’s Department of Health Care Services (DHCS). The study was approved by the institutional review boards of the University of California, San Francisco and the California Health and Human Services Agency.
|
study
| 99.94 |
We obtained aggregate data on the number of Medi-Cal enrollee women of reproductive age by county to examine the geographic distribution of providers compared to the county-level geographic distribution of eligible women and to calculate abortion rates. We also obtained aggregate data on births to the Medi-Cal FFS population for 2012 (2011 data were not available) to calculate abortion ratios.
|
study
| 99.94 |
Medi-Cal is administered on a fee-for-service or managed care arrangement, with roughly equal numbers of women enrolled in each at the time of the study. Pregnant women have four options for health care coverage under Medi-Cal: Full-coverage Medi-Cal, Pregnancy-related Medi-Cal (covering pregnancy-related healthcare only), Presumptive Eligibility for Pregnant Women (temporary pregnancy-only coverage), and Medi-Cal Access Program (for those women whose incomes are too high to qualify for Medi-Cal, coverage of all healthcare during and shortly after pregnancy for a low-cost premium). While the California Department of Health Care Services considers the Medi-Cal Access Program and Presumptive Eligibility for Pregnant Women fee-for-service programs, only the traditional fee-for-service billing records (both full-coverage and pregnancy-only) contain complete information for care provided to the beneficiary; therefore, we requested data only for those beneficiaries with traditional fee-for-service coverage. These claims represent approximately one quarter of all Medi-Cal covered abortions .
|
study
| 99.9 |
For each Medi-Cal beneficiary, the dataset included an encrypted ID number, date of birth, city, state, zip code, longitude and latitude of the beneficiary residence, race, date(s) of service, diagnoses (International Classification of Diseases, 9th Revision [ICD-9] codes), and procedures or treatments. For each procedure, the dataset also included the provider number, the address, city, state, zip code where provider is registered, the facility type, and amount paid per individual treatment. For additional details on data preparation, see Additional File 1.
|
study
| 99.94 |
The primary outcome of interest was the distance that each beneficiary traveled to obtain her abortion. We used TRAVELTIME3, a STATA module that uses a Google Maps application programming interface (API) to calculate distance traveled and travel time via road to the provider for each beneficiary [34, 35]. We categorized the distance variable into four groups: <25 miles, 25–49 miles, 50–99 miles, and 100+ miles. We also dichotomized distances and times to less than 50 miles or 50 miles or more, and examined which factors were associated with greater distances traveled to seek abortion care.
|
study
| 100.0 |
We also quantified the number of abortion providing facilities. We first estimated the number of facilities reimbursed for at least one abortion over the two years. We also estimated the number of facilities reimbursed for at least 50 abortions over the two years as an indicator of facilities that routinely accepted Medi-Cal for abortion. Among those facilities providing at least 50 total abortions, we also calculated the proportion providing at least one medication abortion, first trimester aspiration abortion, and second trimester or later abortion.
|
study
| 99.94 |
First we present the characteristics of the sample and estimated median distance traveled by age, race, urban/rural residence, procedure type (medication abortion, first trimester aspiration, second trimester or later abortion), and source of care. We then present the proportion of women traveling <25 miles, 25–49 miles, 50–99 miles, and 100+ miles for each of these characteristics. We then built a multivariable mixed-effects logistic regression model to examine the factors associated with traveling 50 miles or more to obtain an abortion, accounting for clustering of multiple abortions by the same woman using random effects specifications. We did not include the rural/urban indicator in the model because it was highly correlated with the outcome, distance traveled. In these analyses, the abortion is the unit of analysis.
|
study
| 100.0 |
Next we estimated the median reimbursement for all related services on the day(s) of abortion by procedure type. Finally, we examined the distribution of Medi-Cal FFS abortion-providing facilities by county. We counted facilities reimbursed for at least one and at least 50 abortions and classified facilities by county. We tested for associations between presence of, number of, and distance traveled to facilities and Medi-Cal FFS abortion rates and ratios at the county level. We used t-tests for presence of facility comparisons and linear regression to examine number of facilities and median distances. We examined the percentage of facilities performing medication abortion, first trimester aspiration abortion, and second trimester or later abortion. To test the hypothesis of whether factors beyond long distances from care, such as fertility preferences or attitudes towards abortion, cause differences in urban/rural abortion access, we also developed several models to examine abortion rates among rural and urban women. Using census data on percent of county population residing in a rural location, we examined whether median distance traveled for abortion, abortion rates, or abortion ratios differed by the percent of county living rurally, using linear regression . Statistical significance was set at p < 0.05 for all comparisons and adjusted odds ratios (AORs) and 95% confidence intervals are reported. All statistical analyses were performed using STATA 14.1. In accordance with DHCS Public Reporting Guidelines, cells smaller than n = 11 were suppressed.
|
study
| 100.0 |
The dataset contained 39,747 abortions obtained by 36,720 beneficiaries of the Medi-Cal FFS program in 2011 and 2012. Among these abortions, 89% had a full and valid address available for both beneficiary and provider. Of those missing an address (n = 4316), 99% were missing the beneficiary address; the remaining 1% (n = 31) had addresses out of state or without identifiable driving distance. Of those missing distance, 98% were under the age of 21 and covered by a specific minor consent program; the Medi-Cal program suppresses data for these participants. For this analysis, we excluded those missing distance. Our final analytic sample thus included 35,431 abortions to 32,582 women.
|
study
| 99.94 |
The median age of the population was 26; the largest proportion of the population was Hispanic/Latina (50%), followed by white (25%), black (13%) and Asian (5%) (see Table 1). Of all abortions, 28% were medication abortions, 56% were first trimester aspiration abortions, and 16% were second trimester or later abortions. The majority took place in outpatient clinics (56%), followed by physician’s offices or groups (36%) and hospitals (7%).Table 1Characteristics of Women Obtaining Abortions Covered by Medi-Cal, 2011–2012n%Total35431100Sociodemographics Age, yearsa 17 or younger11543.3 18–241427240.3 25–341556143.9 35 or older443812.5 Race/ethnicity Non-Hispanic white895125.3 Non-Hispanic black443212.5 Hispanic/Latina1776850.1 Asian19345.5 Other12693.6 Declined to state/missing10773.0 Residence Urban3173489.6 Rural369710.4Characteristics of abortion Abortion procedure Medication abortion1003728.3 1st Trimester aspiration1981955.9 2nd Trimester or later557515.7 Source of care Hospital25287.1 Outpatient clinic2001556.5 Physician’s office/Physician’s group1288836.4 Data year 20111921554.2 20121621645.8 Distance traveled for care < 25 miles2668375.2 25–49 miles454012.8 50–99 miles27407.7 100+ miles14684.1 aData on women missing age are not presented due to small numbers
|
study
| 99.94 |
Among all women, the mean distance traveled was 23.5 miles (95% CI: 23.1–23.9), with a range of 0.02 to 661 miles and a median distance traveled of 10.5 miles (95% CI: 10.3–10.7). 11.9% (95% CI: 11.5%–12.2%) traveled 50 miles or more to obtain an abortion and 4.1% (95% CI: 3.9%–4.4%) traveled 100 miles or more (See Table 2). Most likely to travel 50 miles or more and 100 miles or more were women obtaining second trimester or later abortions (21.7% 50+, 9.4% 100+), women obtaining abortions at hospitals (19.9% 50+, 9.9% 100+), and rural women (51.0% 50+, 19.5% 100+). Median distance traveled by abortion type was 8.7 miles for medication abortion (95% CI: 8.4–9.0), 10.2 miles for first trimester aspiration abortion (95% CI: 10.0–10.3), and 15.8 miles for second trimester or later abortion (95% CI: 15.4–16.4).Table 2Proportion of Abortions by Distance Category, Medi-Cal 2011–2012n%0–24 Miles%25–49 Miles%50–99 Miles%100+ MilesMedian distance Traveled (miles)Chi-squared, K-sample equality of medians test Total (N)354312668345402740146810.5 Total (%)75.312.87.74.1Sociodemographics Age, yearsa <0.001 17 or younger115468.716.39.45.611.9 18–241427274.213.18.34.411.2 25–341556175.912.67.54.010.2 35 or older443878.811.86.13.29.3 Race/ethnicity<0.001 Non-Hispanic white895160.419.313.96.417.0 Non-Hispanic black443279.99.68.02.510.3 Hispanic/Latina1776880.510.85.13.58.9 Asian193482.410.84.12.89.4 Other126975.611.08.05.59.4Declined to state/missing107781.111.34.82.811.0 Residence<0.001 Urban3173482.010.75.02.39.2 Rural369719.130.931.519.550.7Characteristics of abortion Abortion procedure<0.001 Medication abortion1003779.512.15.92.58.7 1st Trimester aspiration1981976.612.67.43.510.2 2nd Trimester or later557563.215.012.39.415.8 Source of care<0.001 Hospital252868.811.310.09.99.6 Outpatient clinic2001575.214.07.53.311.0 Physician’s office/Physician’s group1288876.811.37.64.39.9 Data year0.184 20111921575.312.77.94.110.6 20121621675.413.07.54.210.4 aData on missing age not presented due to small numbers
|
study
| 99.94 |
In a multivariable model, several factors were associated with likelihood of traveling 50 miles or more for Medi-Cal FFS funded abortion care (see Table 3). Adolescents and young women under 18 were significantly less likely to travel 50 miles or more compared to women ages 18–24 (AOR = 0.03, 95% CI 0.003–0.37, p < 0.01). Hispanic and Asian women were significantly less likely to travel 50 miles or more compared to white women (p < 0.05). Compared to women obtaining a first trimester aspiration abortion, women obtaining a medication abortion had lower odds of traveling 50 miles or more (p < 0.001) and women obtaining a second trimester or later abortion had over 8 times the odds of traveling 50 miles or more (p < 0.001). Compared to women obtaining an abortion in an outpatient clinic, women going to a physician’s office had 2.8 times higher odds of traveling 50 miles or more (p < 0.001) and those going to a hospital had 6.9 times higher odds of travel 50 miles or more (p < 0.001). There was no difference in odds of traveling 50 miles or more by year.Table 3Odds of Traveling 50 Miles or More for Abortion Covered by Medi-Cal, 2011–2012 (N = 35425a)CharacteristicTraveled 50+ milesAdjusted Odds Ratio95% CISociodemographics Age, yearsa 17 or younger0.03**(0.003,0.37) 18–24RefRef 25–340.58(0.28,1.19) 35 or older0.33(0.08,1.32) Race/Ethnicity Non-Hispanic whiteRefRef Non-Hispanic black0.42(0.14,1.32) Hispanic/Latina0.37*(0.17,0.83) Asian0.02***(0.002,0.19) Other0.22(0.04,1.17) Declined to state/missing0.09*(0.01,0.71)Characteristics of abortion Abortion procedure Medication abortion0.18***(0.08,0.40) 1st Trimester aspirationRefRef 2nd Trimester or later8.81***(4.41,17.61) Source of care Hospital6.88***(2.53,18.70) Outpatient clinicRefRef Physician’s office/Physician’s group2.80**(1.42,5.54) Data year 2011RefRef 20122.84***(1.66,4.85) aAbortions among women missing age (n = 6) were dropped from this analysis*p < 0.05, **p < 0.01, ***p < 0.001
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study
| 99.94 |
Median reimbursement rates for all costs on the day(s) of the abortion differed by abortion procedure. Facilities were reimbursed a median of $475 for medication abortion, $405 for first trimester aspiration abortion and $499 for second trimester or later procedures.
|
other
| 99.9 |
We identified 287 unique locations which were reimbursed by Medi-Cal FFS for at least one abortion. Of these, 65 facilities were reimbursed for only one abortion over the two years and 115 facilities were reimbursed for 50 or more abortions. Of the 58 counties in California, 30 (52% of counties) had facilities that were reimbursed by Medi-Cal FFS for at least 50 abortions; these counties were home to 90% of eligible enrollees (See Table 4). Among facilities providing at least 50 abortions, 69% (79) were reimbursed for first trimester aspiration abortions, 86% (99) were reimbursed for medication abortions, and 55% (63) were reimbursed for second trimester or later abortions. No counties with fewer than 50 abortions had an abortion provider; the 50 abortion cutoff therefore did not exclude low-volume providers meeting demand in counties with few abortions.Table 4Facilities providing 50+ Medi-Cal FFS abortions, median distance, abortion and birth rates, by county 2011–2012CountyNumber of facilities providing at least 50 abortionsMedian distance traveled by women residing in county (miles)Abortion Rate (Abortions per 1000 Medi-Cal FFS female enrollees 15–49)Birth Rate (Medi-Cal FFS funded births per 1000 Medi-Cal FFS female enrollees 15–49, 2012 onlyb)Overall115119.472.1Los Angeles2987.468.6San Diego101013.884.6Santa Clara9712.066.5Orange785.2106.2Sacramento699.054.0Riverside5167.387.7San Francisco5421.056.6Contra Costa4186.060.7San Bernardino4205.868.8San Joaquin475.860.3Alameda31310.358.1Santa Barbara3416.498.4Butte21912.359.1Fresno275.061.6Monterey21610.495.0San Luis Obispo21722.097.7Solano2104.259.3Sonoma2710.2106.7Stanislaus2156.864.8Ventura21014.5112.3Humboldt11411.470.1Kern1134.963.8Madera1235.064.9Mendocino15610.780.5Napa1143.4100.4Placer12014.755.7San Benito11614.373.7Santa Cruz165.9105.7Shasta1717.062.3Sutter14410.266.8Alpine0-a -a -a Amador04711.860.4Calaveras0539.249.9Colusa0607.796.3Del Norte0886.055.4El Dorado04413.562.1Glenn0249.575.4Imperial01197.374.1Inyo02176.171.9Kings0363.060.1Lake06211.256.8Lassen01046.460.6Marin0228.880.4Mariposa06714.263.1Merced0444.280.1Modoc01576.722.6Mono03117.695.9Nevada05516.757.8Plumas0898.750.7San Mateo0129.985.4Sierra01189.7-a Siskiyou0987.359.7Tehama03411.068.7Trinity0649.057.3Tulare0463.063.3Tuolumne05311.457.8Yolo02310.891.0 aSuppressed due to small numbers bBirth data was only available for 2012
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study
| 99.94 |
Median distance traveled for abortion care differed by county, ranging from 4 to 311 miles. Counties with a facility providing at least 50 abortions had significantly lower median distance traveled for care by women in those counties compared to counties without a facility providing abortion (15 miles vs 77 miles, p < 0.001).
|
study
| 99.94 |
To examine whether facility availability impacted abortion utilization, we examined the relationship between facilities and abortions at the county level. We used both abortion rates and ratios because each measure reflects different contexts; abortion rates (abortions per 1000 female Medi-Cal FFS enrollees of reproductive age) relate abortions to the population ‘at-risk’, while abortion ratios (abortions per 1000 Medi-Cal FFS paid births) relate abortions to a measure of fertility. T-tests comparing county level abortion rates and ratios between counties with and without a facility providing 50 or more Medi-Cal FFS abortions found no significant associations (p = 0.29 & p = 0.79, respectively). A linear regression of county level abortion ratios by number of facilities (providing 50 or more abortions) per 10,000 enrollees also found no significant association (p = 0.51), however, the abortion rate was significantly positively associated with the number of facilities per 10,000 enrollees (p = 0.02) (see Fig. 1).Fig. 1County Medi-Cal abortion rates vs. number facilities proving 50+ abortions per 10,000 female reproductive-aged enrollees
|
study
| 100.0 |
At the individual level, rural women traveled longer distances than their urban counterparts (see Table 2). We also found evidence of this at the county level; using census data on percent of population living in urban vs rural zip codes by county, we found that the percentage of a county population that is rural was positively and significantly associated with median distance traveled by women in that county in a linear regression model (p < 0.001). We also used linear regression to examine whether the abortion rate or ratio differed by urban/rural status, regressing percentage of the county population that is rural on abortion rate and on abortion ratio. Neither abortion rate nor ratio significantly differed by percentage of the county population that is rural (p = 0.91 & p = 0.12 respectively).
|
study
| 100.0 |
Despite living in California, a state with liberal abortion laws and relatively good access to abortion , many low-income women with Medicaid travel long distances for publicly funded abortion care. In this study, 12% of women traveled 50 miles or more to obtain a publicly funded abortion. Distances were highest among rural women, about half of whom traveled 50 miles or more. Less than a quarter of the abortion providers in the state provided significant numbers of abortions for the Medicaid program . Only about half of California’s counties had facilities that regularly provided abortion care and accepted Medi-Cal as a form of payment.
|
other
| 99.9 |
The geographic distribution of abortion providers is influenced by a complex set of factors. These factors include community-level fertility preferences and attitudes about abortion, state-level restrictions, unintended pregnancy rates, population density, and the availability of trained abortion providers. Abortion care facilities are concentrated in urban areas, where populations are higher and thus a greater number of women seek abortion. Abortion providers may also concentrate in urban areas due to higher abortion stigma in more rural settings. A national study that found that obstetrician–gynecologists with rural mailing addresses were significantly less likely to perform abortions (6.5%) than their urban counterparts (17.0%) . Maintaining an abortion practice can be difficult and even dangerous in a hostile and isolating environment [15, 38, 39].
|
study
| 99.9 |
Our finding that rural women travel further for care is consistent with previous research in rural women’s health. Rural women are known to experience poorer health outcomes and have less access to health care than urban women . However, the county level findings demonstrate that the abortion rate does not differ by the percent of women living in rural areas. That is, rural women have similar rates of publicly funded abortion as urban women and thus need comparable access to abortion care. This finding conflicts with the earliest study on this topic that suggested that rural women access abortion at lower rates than urban women, and also runs counter to the hypothesis that social and cultural factors cause significant differences in abortion utilization by rural and urban women . The distribution of facilities does not reflect this similar utilization, however.
|
study
| 99.94 |
California has few state restrictions that would result in the closure of abortion facilities [41, 42] compared to many other states, particularly in the South and Midwest . However, as unintended pregnancy and abortion rates decline, the number of abortion providers are also declining . In California, 12 clinics have closed since 2011, likely due in part to decreased demand. The closure of one facility in a city with many clinics may not have widespread impact on access, but the closure of a facility in a more rural setting may dramatically impact how far women in the surrounding areas have to travel for care, if they are able to reach a provider at all. Even a small reduction in the number of providers has the potential to reduce access to care.
|
other
| 99.56 |
We found that black, Latina and Asian women traveled shorter distances than white women, which is also consistent with national findings . This finding could be because women of color may be concentrated in urban centers but could also be in part because women of color are not able to access abortion if they must travel great distances to obtain abortion care .
|
other
| 87.06 |
Women having a second trimester or later abortion or having their procedure at a hospital were also more likely to travel greater distances because there are fewer of these providers. This finding is consistent with national data finding women travel greater distances for later abortions .
|
other
| 93.6 |
Traveling longer distances for care poses challenges beyond extra time in transit, particularly for low income women. Increased travel distance means increased costs for gas or public transit fare, hotel, loss of wages from time off work, and childcare, even though the actual procedure may be covered by public health insurance (as in California) or by abortion funds . These costs can be compounded for low-income women, who may be less likely than wealthier women to own cars or have the flexibility to take time off work. Beyond costs, having to seek care outside of one’s community can add stress by isolating women from familiar surroundings and removing them from potential social support . Women who would need to travel long distances to reach a Medi-Cal provider may instead opt to pay out-of-pocket for a closer provider, eschewing the benefit of Medicaid coverage. If the travel distance, costs, and other barriers are insurmountable, some women carry their unwanted pregnancies to term .
|
other
| 99.9 |
These findings highlight the need to pursue strategies to increase the number and geographic distribution of providers who accept Medi-Cal. Integrating early abortion into primary care settings has been shown to increase access without reducing safety or efficacy, [49, 50] and studies of women’s preferences suggest the majority of women would prefer to obtain an abortion at their primary care provider [51–54]. Increasing the types of providers who are qualified to provide abortion to include those more likely to work in rural and community-health settings than physicians can also increases access . In California, legislation was passed in 2002 allowing nurse practitioners and nurse midwives to administer medication abortion without physician supervision and in 2013 allowing them to conduct first trimester aspiration abortions without physician supervision . Telemedicine programs, where a physician provides medication abortion by providing counseling via videoconference and then releases the medication via remote control, can also be a useful strategy to improve access where abortion providers are scarce .
|
study
| 66.56 |
Finally, efforts to increase the number of providers accepting Medi-Cal as payment for abortion suggest that reimbursement rates for abortion must be reevaluated. National studies have found that Medicaid abortion reimbursement levels are lower than insurance payments and also lower than what women paying out of pocket are charged . In California, the second trimester abortion reimbursement rate by Medi-Cal FFS was substantially lower than private insurance when examined in 2006, less than half that of private insurance in some cases . Reimbursement rates have not changed substantially since then (personal communication, Janley Hsiao, Billing Manager, Women’s Options Center). Increasing the rate of reimbursement, as well as making abortion coverage information clear and available and training Medi-Cal staff on abortion coverage, could potentially increase the number and distribution of providers accepting Medi-Cal.
|
study
| 81.25 |
This study has several limitations. First, this study relies on claims data which may contain erroneous codes . Secondly, the location of the abortion provider may be inaccurate. While we aimed to ensure that we captured the location of abortion provision by use of billing address rather than other addresses, it is possible that the facility used a different administrative address than the location where the abortions occurred, reducing the accuracy of our distance calculation. Third, it is likely that women with Medi-Cal coverage paid out of pocket for abortion care due to difficulty getting Medi-Cal payment, to protect their privacy, or to obtain their abortion from a provider who did not accept Medi-Cal (for reasons of geographic proximity, trust, or a lack of knowledge about Medi-Cal abortion coverage), leading us to have underestimated the total number of abortions in this population. Furthermore, the study did not include women on other Medi-Cal plans including Presumptive Eligibility for Pregnant Women and Medi-Cal Access Program Medi-Cal plans, which are likely composed of younger women living in more urban areas and who would travel shorter distances to a provider. Finally, our data included only reimbursed claims, not all billed claims. It is possible that providers billed for abortions which were not reimbursed due to provider or Medi-Cal error. This could result in underestimation of both abortions and Medi-Cal FFS providers.
|
study
| 100.0 |
In examining the distances that low-income women in California travel for Medicaid-covered abortion care, some women travel substantial distances despite relatively high accessibility in the state. Rural women travel particularly far despite having abortion rates comparable to their urban counterparts, highlighting the need for greater geographic distribution of abortion providers who accept Medicaid. This could be accomplished by increasing the Medi-Cal reimbursement rate, increasing the types of providers who provide abortions (including nurse practitioners, certified nurse midwives, and physician assistants) and expanding use of telemedicine among Medi-Cal providers. If national trends in declining unintended pregnancy and declining abortion rates continue, careful attention should be paid to ensure that reduced demand does not lead to greater disparities in geographic and financial access to abortion care by ensuring that providers accepting Medicaid payment are available and widely distributed.
|
other
| 99.9 |
Semidwarfism of rice improves phenotype (light-interception properties and harvest index), nitrogen responsiveness, and lodging resistance and is thus an important trait worldwide. The International Rice Research Institute produced a cross between Peta, a tall indica variety (culm length, 150–180 cm), characterized by abundant, long hanging leaves, commonly grown in tropical Asia, and Dee-geo-woo-gen (DGWG), a Taiwanese indigenous semidwarf variety, to improve its lodging resistance and light-interception properties. The resulting semidwarf rice variety IR8 (culm length, 90–100 cm), developed in 1966, has dramatically improved rice yields and brought the Green Revolution to tropical Asia .
|
other
| 99.8 |
The semidwarf trait has also been introduced into rice cultivars grown in other countries. In Japan, Hoyoku, Shiranui, and Reihou, which are representative main cultivars grown in the Kyushu region, were developed using the indigenous semidwarf cultivar Jukkoku . A series of cultivars, such as Akihikari and Niigata Wase, were developed in the 1970s in the Tohoku region using the semidwarf cultivar Reimei, which was induced by gamma-ray irradiation of Fujiminori . In the USA, Calrose 76 (culm length, ~90 cm) was developed in 1976 also by gamma-ray irradiation of the japonica variety Calrose (culm length, ~120 cm) [4–6]. In Korea, d47 derived from IR8 was also introduced into Tongil by japonica-indica hybridization .
|
other
| 94.1 |
Advances in genetic research have facilitated the identification of genes responsible for semidwarfism in rice. The incomplete recessive gene d47 is responsible for the semidwarfism of DGWG, the parent line of IR8 [8–10]. Later, the incomplete recessive gene sd1 in Calrose 76 was shown to be allelic to d47 [4, 11, 12]. Moreover, allelic relationships of the semidwarf gene have been found in Taichung Native 1, derived from DGWG; Shiranui, derived from Jukkoku; and d49 in the mutant cultivar Reimei [13, 14]. Finally, all these semidwarf cultivars carry alleles at the sd1 locus, despite their different parentage [14–18]. The sd1 alleles, on the long arm of chromosome 1, encode loss-of-function mutations in GA20-oxidase (OsGA20ox2), which regulates the synthesis of biologically active gibberellins (GAs), which catalyze three steps in the GA biosynthesis pathway [15–18]. Taken together, a single semidwarf gene, sd1, solely confers the semidwarf phenotype of cultivars commonly grown around the world due to its nondetrimental effects on grain yield .
|
study
| 99.94 |
This narrow genetic base of current semidwarf rice cultivars has led to reduced genetic diversity in rice [20–22]. Thus, it is necessary to identify a novel semidwarf gene alternative to sd1 and to utilize it to extend genetic diversity in semidwarf cultivars. A novel dwarf gene, d60, which was found in the semidwarf mutant Hokuriku 100, developed by exposing Koshihikari to 20 kR of gamma radiation [23, 24], is thus of particular importance. Unlike sd1, which is inherited as a single recessive gene, d60 complements the gametic lethal gene gal, which is carried by many rice varieties. Consequently, the cross between Hokuriku 100 and Koshihikari exhibits a unique genotype ratio of 4D60D60 : 4D60d60 : 1d60d60 [23–25].
|
study
| 100.0 |
Although many semidwarf genes allelic to sd1 have been identified in different cultivars (DGWG, Jukkoku, Reimei, and Calrose 76), differences in their influences have not been elucidated. Thus, investigating the differences in ecological and phenotypic traits in relation to yield between d60- and sd1-carrying plants, as well as those among sd1 allelic variants of different origins, will be beneficial for future use of d60 and multiple allelic variants of sd1. The first author developed isogenic semidwarf lines by continuously backcrossing sd1 of Jukkoku (Jukkoku_sd1) and sd1 of Kinuhikari (IR8_sd1) and d60 and both genes into the Koshihikari background and maintained the lines to investigate the resulting traits. Hence, the study was conducted with the following specific objectives: (a) investigate and quantify the differences between d60- and sd1-carrying NILs, in relation to yield, to assess the utility of sd1 and d60 semidwarf genes and (b) sequence NILs by MiSeq to detect the differences between Sd1/sd1 target sites.
|
study
| 100.0 |
As shown in Figure 1, the following rice cultivars were examined: Koshihikari, Koshihikari Jukkoku_sd1 (Koshihikari∗6//Koshihikari/Jukkoku B6F4), Koshihikari IR8_sd1 (Koshihikari∗3//Koshihikari/Kinuhikari B3F3, Kinuhikari carrying sd1 of IR8 ), Koshihikari d60 (Koshihikari∗3//Koshihikari/Hokuriku 100 B3F3), Koshihikari Jukkoku_sd1 plus d60 (Koshihikari Jukkoku_sd1/Koshihikari d60), and Koshihikari IR8_sd1 plus d60 (Koshihikari IR8_sd1/Koshihikari d60). In each backcross experiment, short-culm BCnF2 plants were backcrossed with Koshihikari as the recurrent female parent in each generation. Each semidwarf phenotype was fixed by the BCnF3 generation. The percentage of genetic materials from Koshihikari in the isogenic semidwarf lines was calculated as follows: For Koshihikari carrying Jukkoku_sd1 (B6F4), (1 − (1/2)6) × 100 ≈ 98.4%. For B3F3, (1 − (1/2)3) × 100 = 87.5%.
|
study
| 100.0 |
Rice seeds were collected from stocks kept in a refrigerator. Seeds of each line were immersed in just enough water to cover them. Water was changed every day for 7 days (May 2 to May 8) during germination stimulation. Seedlings were grown in special boxes (30 × 15 × 3 cm) for approximately 20 days in a greenhouse: two seeds were planted in each cell (2 × 2 × 3 cm) in the box on May 11 and 12 and watered twice a day (07:00 and 12:00). Seedlings were then individually transplanted into a paddy field (120 m2: 6.0 × 20.0 m) of the University Farm on June 8. The paddy field received 4.0 kg of basal fertilizer containing nitrogen, phosphorus, and potassium (weight ratio, nitrogen : phosphorus : potassium = 2.6 : 3.2 : 2.6). Except for the period of mid-season drainage (July 10 to July 17), the water level was maintained at 5–7 cm above ground to prevent seedlings from submersing. A herbicide (Joystar L floable) was applied on June 20 to kill weeds growing uncontrollably and the water was then kept at a high enough level to cover the weeds for 1 week. Koshihikari, Koshihikari carrying Jukkoku_sd1, Koshihikari carrying IR8_sd1, Koshihikari carrying d60, Koshihikari carrying d60 and Jukkoku_sd1, and Koshihikari carrying d60 and IR8_sd1 were grown in 4 m2 plots (2 × 2 m) (two instances per line). Basal fertilizer was applied to give 0.43 g/m2 nitrogen, 0.53 g/m2 phosphorus, and 0.53 g/m2 potassium. After ripening, 10 plants per genotype were sampled twice to assess the following traits: panicle heading time, culm length, internode interval, and panicle length.
|
study
| 100.0 |
The time when the tip of the panicle first emerged from the flag leaf sheath was recorded as the heading time for all plants. Ten plants typical of each line were selected. The sampling procedure was performed twice. Sampled plants were air-dried and the following phenotypic traits were assessed or measured: (1) culm length (the length between the ground surface and the panicle end of the main culm), (2) internode length (the lengths between two neighboring internodes of the upper five internodes), and (3) panicle length (the length between the panicle base and the tip of the panicle). Differences in phenotypic traits between each line carrying a semidwarf gene (or genes) and Koshihikari were obtained using the following equation: percent difference = [(measurements of each line) − (measurements of Koshihikari)]/(measurements of Koshihikari) × 100.
|
study
| 100.0 |
An advantage of genomics is the development of a next-generation sequencer that can decode DNA sequences at the giga level. Development of the next-generation DNA sequencer was advanced under the Affordable Care Act aims to realize societal implementation of medical genomics [27, 28]. The desktop-type next-generation sequencer MiSeq has the ability to read 15 million DNA sequences in one run. Generally, whole-genome sequencing analysis required 30 times of the given genome size (30× genome coverage). According to this standard scale, the MiSeq treats only one rice sample per run, because the 15 million DNA amount is just enough to reconstruct a single rice genome. However, it is a big problem that the running cost is excessively high to use the MiSeq at the practical breeding to detect target genes. So, in this study, to achieve a minimum scale to detect target genes with a reasonable cost, we try to detect Jukkoku_sd1 at only 5× rice genome coverage by using the MiSeq. The semidwarf gene sd1 (a loss-of-function mutation of the GA20-oxidase encoding gene) was transferred to Koshihikari by consecutive backcrosses to prepare a semidwarf Koshihikari named Koshihikari Jukkoku_sd1. The Koshihikari Jukkoku_sd1 backcross was used to detect single-nucleotide polymorphisms (SNPs) in Jukkoku-derived sd1 by NGS. Whole-genome analysis was conducted using Koshihikari Jukkoku_sd1 and Koshihikari. Genomic DNA was extracted from each cultivar by the CTAB (hexadecyltrimethylammonium bromide) method. Genomic DNA was tagged and fragmented to an average length of 500 bp using the Nextera® transposome-based approach. After purification of the transposome with DNA Clean & Concentrator™-5 (Zymo Research, Irvine, CA, USA), adaptors for fixation on the flow cell were synthesized at both ends of each fragment using a polymerase chain reaction (PCR). Then, the DNA fragments were subjected to size selection using AMPure XP magnetic beads (Beckman Coulter, Inc., Brea, CA, USA). Finally, qualitative and quantitative measurements were performed using a Fragment Analyzer™ (Advanced Analytical Technologies, Inc., Ankeny, IA, USA) and a Qubit® 2.0 Fluorometer (Thermo Fisher Scientific, Waltham, MA, USA) to prepare a DNA library for NGS. Aiming to achieve 5× rice genome coverage, a MiSeq next-generation sequencer was used to simultaneously analyze five lines; namely, 4-5 ng of five DNA libraries was applied in each MiSeq run. Clusters then were formed on the flow cells by bridge-PCR and each pair-end of a 250 bp read was sequenced. Resulting sequenced reads were mapped using BWA software with the Nipponbare genome as a reference. Then, SNPs and Indels were detected using SAMtools software (http://samtools.sourceforge.net/).
|
study
| 100.0 |
The days to heading were compared (Figure 2). The earliness of varieties of Koshihikari and donors of semidwarf genes is as follows: Koshihikari, an early-medium maturing variety; Jukkoku, a medium-late maturing variety; Kinuhikari, an early-medium maturing variety; and Hokuriku 100, an early-medium maturing variety. The heading panicles were observed first in Koshihikari carrying IR8_sd1 (83 days to heading) and the latest heading panicles were observed in Koshihikari carrying Jukkoku_sd1 or Jukkoku_sd1 plus d60 (93 days to heading). However, the difference in the average number of days to heading was the largest between lines carrying IR8_sd1 (86.5 days) and those carrying d60 (90.5 days), but this 4-day difference was thought to be minor (Figure 2). Thus, it was concluded that the time required for maturing was comparable among lines and the differences in traits, such as panicle length, were attributed to genetic factors.
|
study
| 100.0 |
The mean values of the individual traits in plants of each genotype were calculated and the percent differences relative to the corresponding mean values of Koshihikari were compared. Introduction of a semidwarf gene (or genes) resulted in a reduction in culm length. The mean culm length of Koshihikari was 88.8 cm, while those of lines carrying Jukkoku_sd1, IR8_sd1, d60, Jukkoku_sd1 plus d60, and IR8_sd1 plus d60 were 71.8, 68.5, 65.7, 48.6, and 50.2 cm, respectively (Table 1 and Figure 3). Similarly, internode intervals were also reduced by the introduction of at least one semidwarf gene. While reductions in internode intervals were relatively uniform in lines carrying Jukkoku_sd1 (23.9%, 27.5%, 27.0%, 23.3%, and 19.4%: percent difference, from upper to lower internode intervals), the reduction in length between the third and fourth and between the fourth and fifth internodes was markedly large in lines carrying IR8_sd1 (16.4%, 31.5%, 37.0%, 42.6%, and 45.0%: percent difference, from upper to lower internode intervals). Reductions in internode intervals were relatively uniform in lines carrying d60 (24.2%, 32.6%, 27.4%, 34.5%, and 45.7%: percent difference, from upper to lower internode intervals), while percent differences were larger than those observed in lines carrying Jukkoku_sd1. In the sd1 plus d60 lines, marked reductions were observed in length between neighboring internodes, probably attributed to the additive effect of sd1 and d60 (Table 1 and Figure 3). The interval between the fourth and fifth internodes often disappeared in plants carrying IR8-sd1 and in sd1 plus d60 lines, which showed a marked reduction in length between the lower internodes.
|
study
| 100.0 |
In contrast, as shown in Figure 4, the effect of a semidwarf gene (or genes) on panicle length (−3.0 to +2.5%), which was smaller than that for internode intervals (−16 to −92%), was negligible in practical agriculture. Particularly, the mean length of panicles in the line carrying Jukkoku_sd1 was 16.2 cm, which was solely 2.5% longer than that of Koshihikari. The panicle length of the line carrying Jukkoku_sd1 was longer than that of the original cultivar Koshihikari: not only the mean value but also the value including the standard deviation caused by circumstance. Therefore, there was certain merit in increasing the production of Jukkoku_sd1 as compared to other semidwarf genes.
|
study
| 100.0 |
Using the MiSeq sequencer, we obtained a total read length of 2.79 × 109 bp from the total read number of 9.53 × 106 in Koshihikari Jukkoku_sd1, while a total read length of 1.92 × 109 bp was obtained from a total read number of 6.13 × 106 in Koshihikari. By mapping the read sequences obtained by NGS using Nihonbare genomic DNA as a reference, sequence coverage rates of 93.5% and 88.5% were attained for Koshihikari Jukkoku_sd1 and Koshihikari, respectively, while average depths were 9.17 and 7.29, respectively. Furthermore, vcf files of the entire genomes were prepared and the whole-genome sequence of Koshihikari Jukkoku_sd1 was compared with that of the virtual Koshihikari genome. As a result, three reads were obtained, including Jukkoku_sd1 from Koshihikari Jukkoku_sd1, while three reads of Sd1 were obtained from Koshihikari. The Sd1/sd1 locus (Os01t0883800-01) was localized at positions 38,382,385–38,385,469 from the end of the short arm of chromosome 1 in the Koshihikari genome. The difference observed between the Koshihikari_Sd1/Jukkoku_sd1 alleles was only one SNP from G to T in exon 1 of the GA20-oxidase gene (Figure 5), as reported by Sasaki et al. . In this study, the G to T SNP of the defective GA20-oxidase gene was localized at position 38,382,746 from the end of the short arm of chromosome 1 of Koshihikari. Using this scale of the NGS approach with a coverage of only 5×, the targeted SNP in Jukkoku_sd1 was successfully identified with three reads, with a cost reduced to 1/5 that of the ordinal whole-genome sequencing with a coverage of 30×.
|
study
| 100.0 |
Environmental degradation caused by global warming, postearthquake salt damage, and radioactive contamination and globalization of agricultural markets due to the Trans-Pacific Partnership are serious issues that call for the innovation of new cultivars to overcome the shortcomings of current crops. The results of this study showed that all tested semidwarf lines had shorter culm lengths than Koshihikari, indicating improved lodging resistance. Furthermore, the leaves were straighter (pointing upwards) in the semidwarf lines than in Koshihikari (Figure 1), indicating improved light-interception properties attributed to the introduction of semidwarf gene(s). Panicle length was solely longer by 2.5% in Koshihikari carrying Jukkoku_sd1 and shorter in lines carrying IR8_sd1 by 2.4% or d60 by 3.0%, as compared with the original cultivar Koshihikari (Table 1 and Figure 4). However, the reduction in panicle length was considerably less than that in culm length (Table 1 and Figure 3; a 22.8% decrease in lines carrying IR8_sd1 versus a 26.1% decrease in lines carrying d60), suggesting that the negative effects of the semidwarf genes sd1 and d60 on panicle length were negligible (Table 1 and Figure 4). Ogi et al. and Murai et al. reported that an isogenic line carrying sd1 was derived from DGWG, which was constructed with the genetic background of Norin 29 and Shiokari, respectively. However, IR8-derived sd1 did not show effects of increasing panicle length, which was also observed with the genetic background of Koshihikari in this study. On the other hand, the results showed that Jukkoku-derived sd1 solely increased panicle length by more than 2.5%, as compared to the original cultivar Koshihikari and other semidwarfing alleles.
|
study
| 100.0 |
The first author reported transcription of the sd1 gene derived from Jukkoku . RT-PCR of root RNA showed that the 779 bp fragment derived from the sd1 locus was clearly cleaved into 613 bp and 166 bp fragments by PmaCI digestion on the SNP in Jukkoku_sd1, but there was no cleavage of the Sd1 locus in Koshihikari (Figure 5). This is the first evidence of the transcription of sd1, a defective gene of GA20ox-2. Accordingly, Jukkoku_sd1, which is substituted by only a single nucleotide against the 385 bp-deficient IR_sd1 and is actively transcribed, has no deteriorative effect on the panicle and may have a positive effect on panicle elongation by the overflow of nutrition due to culm reduction.
|
study
| 100.0 |
In Japan, Koshihikari suffers considerable lodging damage as a result of frequent powerful typhoons and, thus, the development of lodging-resistant cultivars has been a long-standing challenge. The first author transferred the semidwarf gene Jukkoku_sd1 to Koshihikari to develop a semidwarf form of Koshihikari which could withstand a typhoon by backcrossing with Koshihikari eight times , with more than 99.8% of the background of the Koshihikari genome, except for Jukkoku_sd1 . This cultivar, which was about 20 cm shorter than Koshihikari, was named Hikarishinseiki (rice cultivar number 12273) [33, 34]. Hikarishinseiki is the first cultivar to be a Koshihikari-type semidwarf with sd1 registered in Japan and USA [35, 36].
|
study
| 54.4 |
In this study, a MiSeq next-generation sequencer was used to achieve 5× rice genome coverage; namely, 4-5 ng of five DNA libraries was applied in one MiSeq run. Using this approach, the targeted gene mutation in Jukkoku_sd1 was successfully detected as the SNP (G to T) in the defective GA20-oxidase gene, which had reduced the culm length by a loss-of-function mutation of GA synthesis, localized at position 38,382,746 from the end of the short arm of chromosome 1 of Koshihikari. This would be the minimum scale to detect Jukkoku_sd1 in practical breeding. In Japan, genetically modified organisms are not acceptable to consumers; thus the target SNP in Jukkoku_sd1 would be effectively tracked by using NGS of 5× coverage scale in each backcrossed generation with Koshihikari. On the other hand, as the DNA sequence and function of sd1 have been deciphered [15–18, 37], new breeding methods, such as RNAi gene silencing and genome editing , are available in other countries to retard culm length by knockout of Sd1.
|
study
| 99.94 |
The effects on phenotypic traits of rice differed between the two semidwarf genes (sd1 and d60) and also between sd1 loci of different origins (Jukkoku_sd1 and IR8_sd1). The effect on culm length was more pronounced in plants carrying d60 than in those carrying sd1 (culm length: Jukkoku_sd1, 71.8 cm; IR8_sd1, 68.5 cm; and d60, 65.7 cm). The reduction in internode intervals was relatively uniform in lines carrying Jukkoku_sd1 or d60 (uniform reduction type), while reductions of the third and lower intervals were larger than in the upper intervals in lines carrying IR8_sd1 (Figure 3 and Table 1). Thus, the center of gravity will be lower in the lower internode reduction type, suggesting higher lodging resistance in lines carrying IR8_sd1 than in those carrying Jukkoku_sd1 or d60. Although the function of d60 is not known, it is clearly distinct from that of sd1, as the additive double-dwarf effect of sd1 and d60 appeared in Jukkoku_sd1 plus d60 and IR8_sd1 plus d60, respectively. The results of this study demonstrated that d60 has a stronger effect than sd1 on culm length and exerts similar effects on other phenotypic traits as with sd1. Although many semidwarf genes are associated with a reduction in panicle length, d60 does not exert such negative effects on phenotypic traits of rice plants. Taken together, these results showed that d60 is useful for adding genetic diversity to semidwarf varieties and is thus of particular importance in the field of plant bleeding.
|
study
| 100.0 |
Most guidelines on chronic cough emphasize the upper airway cough syndrome (UACS), asthma, and gastro-esophageal reflux disease (GERD) as usual causes of chronic cough in nonsmokers with normal chest radiographs.[6–13] However, the data in these recommendations were reported a long time ago.[3–11] Further, the prevalence of diseases that cause chronic cough, such as asthma, GERD, and other comorbidities, differs according to region and ethnicity. The prevalence of asthma is higher in urbanized communities adopting a Western lifestyle; notably, the prevalence of GERD is reported to be 10% to 20% in the Western area but less than 5% in Asia.
|
review
| 99.9 |
In clinical practice, a significant number of smokers complain of chronic cough; therefore, many clinicians have questions about the actual prevalence and clinical characteristics of diseases contributing to chronic cough. Nevertheless, reports on the possible causes of chronic cough are not up to date and any relevant data come from relatively small populations. Additionally, the prevalence study of chronic cough has been rarely reported in the large general population including smokers. Updated research on the prevalence of chronic cough and the impact that various conditions have on it is now mandatory. Moreover, many diseases affecting the respiratory tract show environmental, regional, and ethnic differences, and the same might apply to causes of chronic cough.
|
review
| 99.9 |
Recently published Korean guideline listed the various causes of chronic cough, placing emphasis on the major ones. However, there are still little data on the prevalence of possible causes or the impact of each diseases on chronic cough in general population including smokers.
|
other
| 99.9 |
This study aimed to identify the prevalence of chronic cough and its possible causes, along with the relative impact of each cause on the prevalence of cough in the general population using data from the Korean National Health and Nutrition Examination Survey (KNHANES).
|
study
| 99.94 |
The KNHANES is a collection of nationally representative, cross-sectional, population-based health, and nutritional surveys produced by the Korean Centers for Disease Control and Prevention. Briefly, participants in KNHANES were chosen by proportional allocation sampling with multistage stratification, based on geography, age, and sex. KNHANES includes a health interview, physical examination, laboratory tests, and nutritional questionnaires to assess the health and nutritional status of the noninstitutionalized civilian population of Korea. The health interview included an established questionnaire to determine the demographic and socioeconomic characteristics of the subjects including age, education level, occupation, income, marital status, smoking habits, alcohol consumption, exercise, past and current diseases, and family history. A field survey team including otorhinolaryngologists performed the interviews and physical examinations in a mobile examination unit. All individuals participated voluntarily and provided their written informed consent. The KNAHENS protocol was approved by the Korean Centers for Disease Control and Prevention institutional review board.
|
study
| 99.94 |
Spirometry was performed for subjects aged >40 years according to the guidelines of the American Thoracic Society/European Respiratory Society, using a spirometry system (model 1022; SensorMedics Corporation San Diego, CA). Predicted values were calculated using the predictive equation for the Korean population. Chest radiographs were evaluated and interpreted by a pulmonologist and a radiologist. Quality of life was measured using a validated Korean version of the 5-item self-administered EuroQOL (EQ-5D). An otorhinolaryngologic examinations were performed by trained otorhinolaryngologists according to standardized protocols. Examinations of the nasal cavity were performed using a 4 mm, 0° nasal endoscope before and after decongestion. Laryngoscopic vocal cord examinations were performed using a 4 mm 70° angled rigid endoscope with a CCD camera. The Epidemiologic Survey Committee of the Korean Otorhinolaryngologic Society prepared a protocol for the diagnosis of chronic laryngitis. This committee verified the quality of the survey by periodically visiting the mobile examination units, educating participating doctors, obtaining laryngeal examination data, and data-proofing using video documentation of the larynx throughout the study. Two otorhinolaryngologic surgeons from the Korean Otorhinolaryngologic Society subsequently confirmed the video documentation and assessed the disease decision protocol. Documentation of the video was obtained as 640 × 480-sized Audio Video Interleave files, which were compressed by DivX 4.12 codec using a compression rate of 6 Mb/s.
|
study
| 100.0 |
Rhinitis and chronic sinusitis were diagnosed according to standardized protocols. If symptoms or physical examination indicated rhinitis or chronic sinusitis, UACS was diagnosed. Laryngoscopic findings of laryngitis and/or inflammation, including Reinke edema, pseudosulcus, erythema, or thick endolaryngeal mucus, were diagnosed as chronic laryngitis.
|
other
| 92.9 |
Chronic obstructive pulmonary disease (COPD) was defined as a spirometric result for forced expiratory volume in 1 second/forced vital capacity of <0.7 in adults aged >40 years. A history of asthma, tuberculosis, hypertension, diabetes, hyperlipidemia, and/or cardiac disease was obtained by a self-administered questionnaire asking “Have you been diagnosed with the disease by a doctor?” or “Do you take medicine or treatment for the disease?” Since, many Koreans with COPD are misdiagnosed as having asthma, asthma was only diagnosed if the subject reported a history of asthma but did not meet the criteria for COPD.
|
study
| 99.94 |
Hypertension was defined as blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic, or the use of antihypertensive medications irrespective of the blood pressure status. Diabetes was defined as a fasting plasma glucose level ≥126 mg/dL or hemoglobin A1c ≥6.5%, and/or a current regimen for diabetes treatment. Hyperlipidemia was defined as an abnormal level of high density lipoprotein (<40 mg/dL in male and <50 mg/dL in female participants), a triglyceride level >150 mg/dL, and/or currently taking lipid lowering agents.
|
other
| 99.06 |
KNAHENS was designed using a complex, stratified, multistage probability sampling model, whereby the data were analyzed using the complex sample design to represent prevalence in the Korean population. The analysis was performed using SAS software (version 9.3, SAS Institute, Inc., Cary, NC).
|
study
| 99.0 |
The study population with chronic cough was compared with subjects without chronic cough. The common causes of chronic cough were described according to smoking status to identify the causes of cough in each group. The impact of each condition contributing to chronic cough was also analyzed, adjusting for age, sex, body mass index, smoking status, and comorbidities.
|
study
| 100.0 |
Data from 11,928 adults aged >40 years who completed spirometry in 2010 to 2012 were retrieved from KNHANES. Of these, 302 had chronic cough for more than 3 months (Fig. 1). The overall prevalence of chronic cough in the Korean population aged >40 years was 2.5% ± 0.2%. When compared with people without chronic cough, those with chronic cough were older, male-predominant, and included more current smokers. Hypertension, hyperlipidemia, COPD, diabetes, history of tuberculosis, cardiac disease, asthma, and stroke were more prevalent in subjects with chronic cough. However, the prevalence of chronic laryngitis was not significantly different. The demographic and clinical characteristics of participants are summarized in Table 1.
|
study
| 99.94 |
Of the participants with chronic cough, 47.7% ± 3.8% were current smokers, 45.1% ± 3.9% had nasal symptoms, 42.2% ± 3.7% had an identifiable problem in the nasal cavity, and 46.8% ± 3.9% were suspected to UACS; 26.4 ± 3.5% were compatible with COPD by spirometry, and 14.5 ± 2.8% were compatible with asthma. Chronic laryngitis was used as an alternative to identify GERD-related cough and was presented in 4.1% ± 1.6% of the population. On chest radiography, 4.0% ± 1.2% had an abnormality implying a cause of chronic cough. Patients with chronic cough reported significantly lower quality of life (Table 1).
|
study
| 99.94 |
When the study population was stratified according to smoking status, the following factors were not significantly different between never smokers and former/current smokers: the frequencies of UACS, asthma, chronic laryngitis, abnormal chest radiographs, hypertension, diabetes, hyperlipidemia, stroke, cardiac disease, and history of tuberculosis. However, the prevalence of COPD was higher in current smokers (Table 2 and Table S1).
|
study
| 100.0 |
Given the unified airway theory that causes of chronic cough frequently coexist, we identified the frequency of coexistence of possible causes. When possible causes were classified by current smoking status, UACS, COPD, asthma, and chest radiographic abnormality, 50.3% ± 4.5% of those with chronic cough had coexisting possible causes (Fig. 2). Additionally, 12.7% ± 3.2% of those with chronic cough were suspected to have 3 or more possible causes. However, no possible causes were noted in 14.7% ± 3.1% of subjects. The most highly overlapped conditions were UACS in subjects with asthma (66.9% ± 10.8%) and chest radiographic abnormalities in those with COPD (9.9% ± 4.3%) or asthma (9.4% ± 6.3%) (Table 3).
|
study
| 99.94 |
Since these possible causes, that is, current smoking, postnasal drip, COPD, asthma, and chest radiographic abnormality, are also observed in the population without chronic cough, the odds ratios (ORs) were analyzed to evaluate the impact of these factors on chronic cough. In multivariable analysis, only current smoking status, UACS, COPD, asthma, and abnormal chest radiographs were independently associated with chronic cough, and the adjusted ORs were 3.16, 2.50, 2.41, 8.89, and 2.74, respectively (Table 4). Current smoking, UACS, COPD, asthma, and abnormal chest radiographs were sequentially observed in subjects with chronic cough; however, the impact of chronic cough was strongest for asthma, followed in descending order by current smoking status, chest radiographic abnormality, UACS, and COPD.
|
study
| 100.0 |
We compared the clinical characteristics of the subjects according to current smoking status, UACS, COPD, asthma, and abnormal chest radiographs to determine whether associated symptoms could be used to differentiate causes of chronic cough. The most frequently associated symptom was phlegm (75.9% ± 3.0%). All groups showed a high frequency of chronic sputum production, but the frequency was significantly higher in current smokers (86.9% ± 3.7%). The UACS group reported more episodes of dyspnea and night sweats, and the COPD group reported more occurrences of blood-tinged sputum. However, there was no specific clinical characteristic suggesting asthma or chest radiographic abnormality (Table 5). When clinical characteristics were compared between subjects with a single cause and those with 2 or more causes, subjects with multiple causes complained more frequently of dyspnea and weight loss (Table S2).
|
study
| 99.94 |
To the best of our knowledge, our results are derived from a larger population including smokers than in previous reports[25–35] and ours is the first report on the prevalence of chronic cough in the Korean population. We found the overall prevalence of chronic cough in the general adult Korean population to be 2.5% ± 0.2%, and the common possible causes, in descending order, to be current smoking, UACS, COPD, asthma, and chest radiographic abnormalities. This pattern was not different according to smoking status, although COPD was more prevalent in cigarette smokers.
|
study
| 99.94 |
Individual causes of chronic cough may overlap. In this analysis, UACS frequently accompanied asthma, and chest radiographic abnormalities were frequently observed in subjects with both COPD and asthma. In multivariable analysis, the conditions that cause chronic cough were asthma, current smoking, chest radiographic abnormality, UACS, and COPD, in descending order. More frequently associated symptoms were chronic phlegm for current smokers, dyspnea and night sweats for those with UACS, and blood-tinged sputum for those with COPD.
|
study
| 100.0 |
We believe that our study have some merits and could contribute more to clinical practice. First, previous studies of causes of chronic cough were performed in a relatively small number of patients seen in a specific clinic, so risked selection bias. In this study, although the number of patients with chronic cough may seem small, the survey population selected is regarded as representative of the Korean general population. Second, most of the previous studies excluded smokers or patients with abnormal chest radiographs, and clinicians have had questions about the general frequency of chest radiographic abnormalities and the different characteristics of smokers. Our data showed not only a high prevalence of cigarette smoking (47.7%) in subjects with chronic cough, but also a strong impact of smoking (OR 3.16) on the prevalence of chronic cough independent of underlying diseases. Third, our study found that the prevalence of abnormal chest radiographs, which could be a cause of chronic cough, is 4.0% in the general population. However, the OR for chronic cough was higher than for COPD or UACS, underscoring the importance of chest radiography, especially in a region with a high prevalence of tuberculosis.
|
study
| 99.94 |
Unlike previous research, which reported the prevalence of chronic bronchitis to be 5%, our study reported the prevalence of COPD to be as high as 26.4%. In a previous report, the overall prevalence of COPD in Koreans older than 40 years was 13.4% and increased to 19.4% in men. In our analysis, 12.2% of the total study population had COPD. Focusing on patients with chronic cough, the prevalence of COPD increased to 26.4%. Therefore, physicians should not underestimate the possibility of COPD in patients with chronic cough.
|
study
| 99.94 |
A diagnosis of GERD needs to be confirmed with 24-hour pH monitoring, so the KNHANES data could not show accurately the prevalence or clinical impact of this condition. However, GERD has been reported to be the 3rd most common cause of chronic cough and its frequency is estimated to be 10% to 21%. Otorhinolaryngologic examinations cannot completely replace pH monitoring for diagnosing GERD; however, we used reflux laryngitis as a clue for determining the presence of GERD. Surprizingly, the prevalence of chronic laryngitis was low (4.1% ± 1.6%) and not significantly different from the prevalence in the population without chronic cough (2.7% ± 0.3%). This may imply the fact that GERD-related cough may not be prevalent in the Korean population. Alternatively, the prevalence of GERD in Asian patients may be different from that in previous reports on Western patients with chronic cough. Our data may highlight a need for different algorithms to establish the etiology of chronic cough in different races.
|
study
| 99.94 |
Despite the interesting findings of this study, there are several potential limitations. First, as this study was a cross-sectional analysis, each cause was not confirmed by response to treatment. However, chronic cough is widely known to have multiple causes, and the relative risk for each of these was calculated. Describing the pattern of presentation and considering all possible causes in the general population would be meaningful for physicians encountering patients with chronic cough. Second, the prevalence of asthma was calculated using a self-reported questionnaire and not by a provocation test, so there is a risk of classifying a patient as false positive or as false negative. Although we categorized patients as having asthma diagnosed by their doctor, we acknowledge the possibility of misdiagnosis or underdiagnosis, and there is limitation in differentiating COPD from asthma or asthma-COPD overlap syndrome. Third, we used the prevalence of chronic laryngitis instead of pH monitoring to diagnose. GERD frequently leads to chronic laryngitis;[39–42] however, there are some differences in the mechanism of diseases, and these changes may also appear secondary to smoking, excessive alcohol, allergies, asthma, or voice abuse. Fourth, medication effects, such as those of angiotensin-converting enzyme inhibitors, were not evaluated since most participants did not know the exact name of their prescribed medication. Therefore, we could not determine the prevalence of angiotensin-converting enzyme inhibitor-related cough. Finally, we did not identify other diseases causing chronic cough that could be diagnosed by other methods, such as sputum analysis, computed tomography, or bronchoscopy. Therefore, the number of patients who cannot find the cause of cough may be overestimated.
|
study
| 99.94 |
In conclusion, GERD-related cough is not prevalent in Korean population, and more attention should be paid to smoking and COPD in subjects with chronic cough along with asthma or UACS. Further effort to develop a protocol for chronic cough is necessary for Asian populations.
|
other
| 91.4 |
Generally, the behaviour of biological and cognitive systems is not steadily poised at one phase or another. Instead, living beings operate around points of critical activity, at the boundary separating ordered and disordered dynamics. Critical activity, or criticality, refers to a distinctive set of properties found at this transition. Some of these properties include the presence of a wide range of scales of activity and maximal sensitivity to external fluctuations1,2, facilitating systems at criticality to present optimal responses when facing complex heterogeneous environments3. The surprising fact is that, unlike unanimated matter where critical transitions from order to disorder take place by fine-tuning of the parameters of the system1, living systems appear to be ubiquitously poised near critical points4. For instance, signatures of criticality have been detected in neural cultures5, immune receptor proteins6, the network of genes controlling morphogenesis in fly embryos7 and bacterial clustering8. Indicators of critical behaviour have also been observed in the brain9 and cognitive behavioural patterns10.
|
review
| 99.7 |
Although these results suggest that general theoretical principles might underlie biological self-organization, there is no well-founded theory yet for understanding how living systems operate near critical points in a broad range of contexts. This compels us to ask what type of mechanisms are driving biological systems at a dauntingly diverse span of levels of organization to operate near critical points of activity. During the last couple of decades, the issue has been popularized as the ‘adaptation to the edge of chaos’11 and different solutions have been tested through modelling approaches. However, as we have stated, this question is still unresolved and a general mathematical framework for understanding how living systems are driven to criticality is yet lacking.
|
study
| 96.1 |
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