Advancing beyond the Hippocampus to Preserve Cognition for Patients with Brain Metastases: Dosimetric Results from a Phase 2 Trial of Memory-Avoidance Whole Brain Radiotherapy

PURPOSE/OBJECTIVE(S)

Recent advances to preserve neurocognitive function in patients treated for brain metastases include stereotactic radiosurgery (SRS), hippocampal avoidance whole brain radiation therapy (HA-WBRT), and memantine administration. However, 23% of patients receiving HA-WBRT and memantine on NRG-CC001 still experienced executive function deterioration at 4 months, with 12% experiencing total recall and delayed recognition deterioration at 6 months. The hippocampus, corpus callosum, fornix, and amygdala are key neurocognitive substructures with a low propensity for brain metastases. Herein, we report our preliminary experience using an advanced "memory-avoidance" WBRT (MA-WBRT) approach sparing these substructures for patients with multiple (>15) brain metastases.

MATERIALS/METHODS

Ten consecutive patients treated with MA-WBRT on a phase 2 clinical trial (OSU-21074) were reviewed. In each patient, the hippocampi, amygdalae, corpus callosa, and fornix were contoured. Patients were not eligible for MA-WBRT if they had metastases in these substructures. A memory- avoidance region created using a 5mm volumetric expansion around these substructures. Hotspots were avoided in the hypothalamus and pituitary gland. Dose constraints for these avoidance structures were modeled after NRG CC-001 and include a D100% ≤ 9 Gy and a D0.03 cc ≤ 16 (acceptable to 20 Gy). Coverage of brain metastases was prioritized over memory avoidance dose constraints. Linac-based volumetric modulated arc therapy (VMAT) plans were generated for a prescription dose of 30 Gy in 10 fractions.

RESULTS

On average, the memory avoidance structure volume was 37.1 ccs (Range: 25.2-44.6 ccs), occupying 2.5% of the entire whole brain target volume. All treatment plans met the D100% dose constraint, and 8/10 plans met the D0.03cc constraint, with priority given to tumor coverage for the remaining 2 cases. VMAT spared the memory avoidance structures with a median dose range of 10.8-14.2 Gy and a maximum dose (D0.03cc) range of 15.6-22.7 Gy. The mean dose to the memory avoidance structures was 12.7 Gy (Range: 11.5-13.8 Gy). Target coverage (D98% > 25 Gy) and homogeneity (D2% ≤ 37.5 Gy) were achieved for all plans.

CONCLUSION

Modern VMAT techniques allow for sparing of the hippocampus, amygdala, corpus callosum, and fornix with good target coverage and homogeneity. Prospective quality of life and cognitive data including are being collected and include the Functional Assessment of Cancer Therapy - Brain (Fact-Br), Hopkins Verbal Learning Test (HLVT-R), Trail Making Test A/B (TMT-A/B) and Controlled Oral Word Association Test (COWAT). After enrollment is completed, these data will be evaluated to assess the efficacy of MA-WBRT to mitigate declines in quality of life and cognition after whole brain radiation.

Pulse Parameters and Thresholds for (ir)Reversible Electroporation on Hepatocellular Carcinoma Cells in Vitro

Hepatocellular carcinoma is a leading cause of cancer-related death in many parts of the world. Traditional treatment options are not always effective. During the promising minimally invasive electroporation-based therapies, biological cell membranes are exposed to an external, sufficiently high, pulsed electric field which creates so-called nanopores into the lipid bilayer of the cell membrane. These pores can either be permanent (irreversible electroporation (IRE)), leading to apoptosis, or repairable (reversible electroporation (RE)), with continued cell function. In tumor therapy, RE is used to increase the diffusion of a chemotherapeutic drug during electrochemotherapy. For both IRE and RE, the success of the treatment is dependent on application of the appropriate electric field. Therefore, this study aims to define the pulse parameters and thresholds for IRE and RE on hepatocellular carcinoma (HepG2) cells in-vitro.In a custom-made in-vitro setup, HepG2 cell viability (0, 5, 10, and 15 min), and the peak temperature were measured after electroporation with the different IRE and RE pulsing protocols, to determine the most successful settings for IRE and RE. A CAM/PI flow cytometric assay was performed to confirm cell permeabilization for the RE pulsing protocols with the highest cell viability.The results indicated that an IRE pulsing protocol (70 pulses, 100 µs pulse length, and 100 ms interval) with an electric field strength of 4000 V/cm was needed as threshold for almost complete cell death of HepG2 cells. A RE pulsing protocol (8 pulses, 100 µs pulse length, and 1000 ms interval) with an electric field strength of 1000 V/cm was needed as threshold for viable and permeabilized HepG2 cells. The low peak temperatures (max 30.1°C for IRE, max 23.1°C for RE) within this study indicated that the reduction in HepG2 cell viability was caused by the applied electric field and was not a result of Joule heating.

Dual Task Performance Is Associated with Amyloidosis in Cognitively Healthy Adults

BACKGROUND

Preclinical Alzheimer's disease (AD) provides an opportunity for the study and implementation of interventions and strategies aimed at delaying, mitigating, and preventing AD. While this preclinical state is an ideal target, it is difficult to identify efficiently and cost-effectively. Recent findings have suggested that cognitive-motor dual task paradigms may provide additional inference.

OBJECTIVES

Investigate the relationship between dual task performance and amyloidosis, suggestive of preclinical Alzheimer's disease and whether dual task performance provides additional information beyond a cognitive composite, to help in the identification of amyloidosis.

DESIGN

Cross-sectional.

SETTING

Outpatient specialty brain health clinical research institution in the United States.

PARTICIPANTS

52 cognitively healthy adults.

MEASUREMENTS

The data included demographics, amyloid standardized uptake value ratio obtained via florbetapir-PET, neuropsychological testing, apolipoprotien E genotype, and dual task performance measures. Data were analyzed via hierarchal multiple linear regression or logistic regression, controlling for age, education, and apolipoprotien E genotype. Receiver operating characteristic curves were plotted, and sensitivity and specificity calculated via 2x2 contingency tables.

RESULTS

There was a moderate relationship (rs>.30) between motor and cognitive dual task effects and amyloid standardized uptake value ratio (ps<.042). A strong relationship (r=.58) was found between combined dual task effect, a measure of automaticity derived from dual task performance, and amyloid standardized uptake value ratio (p<.001). Additionally, combined dual task effect showed promise in its unique contributions to amyloid standardized uptake value ratio, accounting for 7.8% of amyloid standardized uptake value ratio variance beyond cognitive composite scores (p=.018). Additionally, when incorporated into the cognitive composite, combined dual task effect resulted in improved diagnostic accuracy for determining elevated amyloid standardized uptake value ratio, and increased the sensitivity and specificity of the cognitive composite.

CONCLUSSION

Dual task performance using the combined dual task effect, a measure of automaticity, was a moderate predictor of cerebral amyloidosis, which suggests that it has utility in the screening and diagnosis of individuals for preclinical AD. Additionally, when combined with the cognitive composite, the combined dual task effect improves diagnostic accuracy. Further research is warranted.

A comparison of structural features and vulnerability between government and nongovernment alcohol and other drug (AOD) treatment providers

OBJECTIVE

Both public (government-run), and not-for-profit (nongovernment) service providers provide alcohol and other drug (AOD) treatment services. Research has rarely studied the structural features of these providers, such as workforce characteristics, procurement arrangements, and funding security. The study reported here sought to document and analyze the differences between these two AOD treatment provider types in Australia.

METHODS

The study administered an online survey instrument targeted at managers of AOD treatment sites. The survey comprised three sections: (1) the service (e.g., treatment types); (2) workforce (e.g., total number of staff); and (3) funding and procurement arrangements (e.g., contract length). The study completed a total of 207 site surveys. The studied compared government and nongovernment services on structural features that may create a more or less sustainable or vulnerable service (funding arrangements, payment mechanisms, and contract length).

RESULTS

Government providers were more likely to provide medically oriented treatment types such as withdrawal management and pharmacotherapy, whereas nongovernment organization (NGO) providers were more likely to offer rehabilitation. Consistent with this, government services were more likely to employ medical professionals and nurses, indicative of a more medically oriented workforce, while NGO services were more likely to employ AOD workers, youth workers, peer workers, and counselors. Our data illustrate that NGO services were more likely to be subject to competitive tendering and to have shorter contract lengths, compared with government services, and overall to be more structurally vulnerable.

CONCLUSION

Despite the reliance on NGOs to provide the majority of specialist care (71% of all treatment episodes in Australia), these services are more vulnerable than their government counterparts. To ensure that a comprehensive suite of treatment services is available, procurement arrangements that support stability and security in nongovernment service providers and government service providers are essential.

Bio-inspired Model of Humanoid Robot for Ascending Movement

Stair climbing is one of the important daily life activities that biped robots have to carry out. However, the number of researches study the ascending movement mechanisms and its stability is low. In this study, we have inspired by human ascending movement underlying mechanisms and developed a new control law based on the nature of the human motor behavior. This model has been developed in phase space using an intermittent sliding mode controller to give stable control and eliminate the effect of the system's uncertainty. A planar five-link biped model has been used to test the model. The embedded space and controller has been formed for each joint separately. Therefore, in this case, the position of each angle in embedded space gets compared along time with its corresponding desired dynamic. The position of each angle in space regarding its corresponding reference trajectory made the error signal. Results show that the designed sliding mode controllers successfully keeps the trajectory near the desired dynamics, and the output follows the desired dynamic very well.

C-03 The sensitivity and specificity of the Montreal Cognitive Assessment is Age Dependent for Amyloid Positivity in a Mixed Clinical Sample

Objective

The Montreal Cognitive Assessment (MoCA) is a widely-used screening tool for neurodegenerative disorders. Despite widespread use, there have been few investigations into correlations between MoCA and biomarkers of Alzheimer's disease pathology. This study examined the relationship between MoCA performance and the presence of amyloid as detected by positron emission tomography (PET).

Methods

Sensitivity and specificity for the total MoCA score were determined for 76 individuals (26 amyloid-negative, 50 amyloid- positive) who were between the ages of 55 and 90 and diagnosed with MCI or mild dementia with a CDR score of 0-1 and were participating in a longitudinal, observational study at the Cleveland Clinic Lou Ruvo Center for Brain Health. All individuals underwent an amyloid PET scan and cognitive screening.

Results

Sensitivity and specificity for the total score were determined using amyloid positivity as the standard. A cutpoint of 25 yielded the best balance between sensitivity and specificity (74% and 74%, respectively). A total score of 27 was required to achieve 90% sensitivity to identify amyloid positive individuals (i.e. only a 10% risk that individuals with a score of 28-30 have a positive scan). A score of 26 was required in individuals over the age of 75.

Conclusions

With the emergence of new diagnostic biomarkers, there is need to define the utility of affordable, widely-available screening tools. In this mixed clinical sample, the MoCA score showed good sensitivity for detecting amyloid pathology but with low specificity. Thus a total MoCA score of 28 is needed to confidently rule out risk for AD pathology.

C-02 An Unbiased Biomarker Approach to Neuropsychological, Behavioral, and Psychiatric Symptoms in a Mixed Clinical Sample

Objective

Suspected Non-Alzheimer’s Pathology (SNAPs) are individuals who present with a cognitive syndrome meeting clinical criteria for Alzheimer’s disease (AD) but are found to lack underlying AD pathology. Current clinical criteria for AD lack specificity in predicting underlying neurodegenerative pathology. With the advent of amyloid positron emission tomography (PET) the presence of amyloid pathology can now be identified in vivo. Using a biomarker-based approach, we aimed to characterize the neuropsychological, behavioral, and psychiatric profile of SNAPs in contrast to those with AD pathology (APs).

Method

76 individuals (26 amyloid-negative [SNAPs], 50 amyloid- positive [APs]) completed neuropsychological testing and a PET amyloid scan as a part of a longitudinal observational study at the Cleveland Clinic LRCBH. Individuals meeting NIA-A criteria for MCI or mild AD with a Clinical Dementia Rating score of .05 -1 were included. Amyloid status was determined via clinical read of two clinicians trained in reading amyloid scans (neuroradiologist and neuropsychiatrist). Independent samples t tests assessed group differences between SNAPs and APs across cognitive, behavioral, and psychiatric measures.

Results

Mini-Mental State Examination scores were equivalent between SNAPs and APs. SNAPs performed significantly better on measures of verbal and nonverbal memory, set-shifting, and semantic fluency, as well as aspects of processing speed and working memory (all p’s < .05). Additionally, SNAPs endorsed more RBD symptoms (p < .05). No significant group differences were observed across neuropsychiatric or functional measures.

Conclusion(s)

Differences in an individual’s neuropsychological, behavioral, and psychiatric profile in consideration with a biomarker approach may provide key insights and afford greater diagnostic clarity.

Geographic variation in surgical practice patterns and outcomes for resected nonmetastatic gastric cancer in Ontario

Background

Gastrectomy with negative resection margins and adequate lymph node dissection is the cornerstone of curative treatment for gastric cancer (gc). However, gastrectomy is a complex and invasive operation with significant morbidity and mortality. Little is known about surgical practice patterns or short- and long-term outcomes in early-stage gc in Canada.

Methods

We undertook a population-based retrospective cohort study of patients with gc diagnosed between 1 April 2005 and 31 March 2008. Chart review provided clinical and operative details such as disease stage, primary tumour location, surgical approach, operation, lymph nodes, and resection margins. Administrative data provided patient demographics, geography, and vital status. Variations in treatment and outcomes were compared for 14 local health integration networks. Descriptive statistics and log-rank tests were used to examine geographic variation.

Results

We identified 722 patients with nonmetastatic resected gc. We documented significant provincial variation in case mix, including primary tumour location, stage at diagnosis, and tumour grade. Short-term surgical outcomes varied across the province. The percentage of patients with 15 or fewer lymph nodes removed and examined varied from 41.8% to 73.8% (p = 0.02), and the rate of positive surgical margins ranged from 15.2% to 50.0% (p = 0.002). The 30-day surgical mortality rates did not vary statistically significantly across the province (p = 0.13); however, rates ranged from 0% to 16.7%. Overall 5-year survival was 44% and ranged from 31% to 55% across the province.

Conclusions

This cohort of patients with resected stages i-iii gc is the largest analyzed in Canada, providing important historical information about treatment outcomes. Understanding the causes of regional variation will support interventions aiming to improve gc operative outcomes in the cancer system.

Deficient primary cilia in obese adipose-derived mesenchymal stem cells: obesity, a secondary ciliopathy?

Obesity alters the composition, structure and function of adipose tissue, characterized by chronic inflammation, insulin resistance and metabolic dysfunction. Adipose-derived mesenchymal stem cells (ASCs) are responsible for cell renewal, spontaneous repair and immunomodulation in adipose tissue. Increasing evidence highlights that ASCs are deficient in obesity, and the underlying mechanisms are not well understood. We have recently shown that obese ASCs have defective primary cilia, which are shortened and unable to properly respond to stimuli. Impaired cilia compromise ASC functions. This work suggests an intertwined connection of obesity, defective cilia and dysfunctional ASCs. We have here discussed the current data regarding defective cilia in various cell types in obesity. Based on these observations, we hypothesize that obesity, a systemic chronic metainflammation, could impair cilia in diverse ciliated cells, like pancreatic islet cells, stem cells and hypothalamic neurons, making these critical cells dysfunctional by shutting down their signal sensors and transducers. In this context, obesity may represent a secondary form of ciliopathy induced by obesity-related inflammation and metabolic dysfunction. Reactivation of ciliated cells might be an alternative strategy to combat obesity and its associated diseases.

Insight into the development of obesity: functional alterations of adipose-derived mesenchymal stem cells

Obesity is associated with a variety of disorders including cardiovascular diseases, diabetes mellitus and cancer. Obesity changes the composition and structure of adipose tissue, linked to pro-inflammatory environment, endocrine/metabolic dysfunction, insulin resistance and oxidative stress. Adipose-derived mesenchymal stem cells (ASCs) have multiple functions like cell renewal, spontaneous repair and homeostasis in adipose tissue. In this review article, we have summarized the recent data highlighting that ASCs in obesity are defective in various functionalities and properties including differentiation, angiogenesis, motility, multipotent state, metabolism and immunomodulation. Inflammatory milieu, hypoxia and abnormal metabolites in obese tissue are crucial for impairing the functions of ASCs. Further work is required to explore the precise molecular mechanisms underlying its alterations and impairments. Based on these data, we suggest that deregulated ASCs, possibly also other mesenchymal stem cells, are important in promoting the development of obesity. Restoration of ASCs/mesenchymal stem cells might be an additional strategy to combat obesity and its associated diseases.

Incontinence after brain injury: prevalence, outcome and multidisciplinary management on a neurological rehabilitation unit

Objective: To investigate the prevalence, outcome and multidisciplinary management of incontinence in patients with acquired brain injury.

Design: Retrospective case notes review.

Setting: Regional neurological rehabilitation unit. Subjects: Two hundred and thirty-eight patients with acquired brain injury.

Main measures: Bladder and bowel subscores of the Barthel Index and Functional Independence Measure; number of multidisciplinary goals addressing bladder and bowel function.

Results: Fifty per cent of patients (n=112) had impaired bladder or bowel subscores on admission. Significant improvement was seen at discharge but 36% of patients (n=77) still had some degree of impairment. Over 90% of patients were set multidisciplinary goals addressing self-care (n=213) and mobility (n=205) but only 3.5% (n=8) were set multidisciplinary goals addressing bladder and bowel function.

Conclusions: Incontinence was common in patients with brain injury on a neurological rehabilitation unit. Significant improvement was seen following rehabilitation. Bladder and bowel management was not well incorporated into the multidisciplinary management process.

Does enhancing consciousness for strategic planning processes support the effectiveness of problem-based learning concepts in biomedical education?

Interdisciplinary skills gain increasing importance in university and professional contexts. To support these interdisciplinary skills, problem-based learning (PBL) is regularly used in a course for biomedical education. In this study, we investigated whether enhancing consciousness for planning processes can support the effectiveness of PBL concepts in an intervention-control group design. Results indicated clear evidence for this: planning skills were associated with better PBL performance. Concluding, self-reflection of planning skills is useful to increase outcome performance of students in PBL courses.

Massenspektrometrische Bestimmung von Bindungsenergien in siliciumorganischen Verbindungen / Mass-spectrometric Determination of Bond Dissoziation Energies in Organosilicon Compounds

The appearance potentials for a large number of organosilicon ions have been measured. Combination of these values with thermochemical heats of combustion allow the determination of bond energy terms which may be used to calculate heats of formation for all silicon compounds containing hydrogen, alkyl and chlorine ligands. The bond dissoziation energies D(Si - H)= 89 ± 4, D(Si - C) = 85 ± 4 and D (Si - Si) =75 ± 8 kcal/Mol were found to be independent of the number of methylgroups attached to silicon. In addition the Si - Cl bond energy was found to be 116 and 104 kcal/Mol in (CH3)3SiCl and Cl3SiCl respectively.

Cellular effects of bacterial N-3-Oxo-dodecanoyl-L-Homoserine lactone on the sponge Suberites domuncula (Olivi, 1792): insights into an intimate inter-kingdom dialogue

Sponges and bacteria have lived together in complex consortia for 700 million years. As filter feeders, sponges prey on bacteria. Nevertheless, some bacteria are associated with sponges in symbiotic relationships. To enable this association, sponges and bacteria are likely to have developed molecular communication systems. These may include molecules such as N-acyl-_L-homoserine lactones, produced by Gram-negative bacteria also within sponges. In this study, we examined the role of N-3-oxododecanoyl-_L-homoserine lactone (3-oxo-C₁₂-HSL) on the expression of immune and apoptotic genes of the host sponge Suberites domuncula. This molecule seemed to inhibit the sponge innate immune system through a decrease of the expression of genes coding for proteins sensing the bacterial membrane: a Toll-Like Receptor and a Toll-like Receptor Associated Factor 6 and for an anti-bacterial perforin-like molecule. The expression of the pro-apoptotic caspase-like 3/7 gene decreased as well, whereas the level of mRNA of anti-apoptotic genes Bcl-2 Homolog Proteins did not change. Then, we demonstrated the differential expression of proteins in presence of this 3-oxo-C₁₂-HSL using 3D sponge cell cultures. Proteins involved in the first steps of the endocytosis process were highlighted using the 2D electrophoresis protein separation and the MALDI-TOF/TOF protein characterization: α and β subunits of the lysosomal ATPase, a cognin, cofilins-related proteins and cytoskeleton proteins actin, α tubulin and α actinin. The genetic expression of some of these proteins was subsequently followed. We propose that the 3-oxo-C₁₂-HSL may participate in the tolerance of the sponge apoptotic and immune systems towards the presence of bacteria. Besides, the sponge may sense the 3-oxo-C₁₂-HSL as a molecular evidence of the bacterial presence and/or density in order to regulate the populations of symbiotic bacteria in the sponge. This study is the first report of a bacterial secreted molecule acting on sponge cells and regulating the symbiotic relationship.

Laser heat hyperalgesia is not a feature of non-specific chronic low back pain

BACKGROUND

Based upon studies using mechanical pin-prick, pressure, electrical or heat stimuli applied to painful and/or pain-free parts of the body, chronic low back pain (CLBP) has been shown to be associated with generalized and enhanced pain sensitivity and altered brain responses to noxious stimuli. To date, no study examined the processing of noxious laser heat pulses, which are known to selectively excite thermal nociceptors located in the superficial skin layers, in CLBP.

METHODS

We studied laser heat pain thresholds (LHPTs) and nociceptive laser-evoked brain electrical potentials (LEPs) following skin stimulation of the pain-affected back and the pain-free abdomen using noxious laser heat stimulation in 16 CLBP patients and 16 age- and gender-matched healthy controls (HCs).

RESULTS

We observed no statistically significant differences in LHPTs between CLBP patients and HCs, neither on the back nor on the abdomen. Furthermore, we found no evidence for altered brain responses between CLBP patients and HCs in response to stimulation of the back and abdomen in single-trial latencies and amplitudes of LEP components (N2, P2).

CONCLUSION

The results are in contrast to previous studies showing hypersensitivity to different experimental noxious stimuli (e.g., contact heat). We argue that these discrepancies may be due to low spatial and temporal summation within the central nervous system following laser heat stimulation. Our results indicate important methodological differences between laser heat and thermode stimulation that should be taken into account when interpreting results, such as from thermal quantitative sensory testing.

[Dirofilariosis: subconjunctival infection with Dirofilaria repens]

A 45-year-old female patient from Bosnia complained of recurrent swelling and redness of the upper eyelid and 24 h later the patient consulted the Salzburg eye hospital because of a subconjunctival swelling. The slit lamp investigation showed a living Dirofilaria repens which could be removed by forceps. On the basis of this case the infection pathway, possible increasing incidence and therapy are discussed.

Isolation and functional characterization of pericytes derived from hamster skeletal muscle

AIM

At the interface of tissue and capillaries, pericytes (PC) may generate electrical signals to be conducted along the skeletal muscle vascular network, but they are functionally not well characterized. We aimed to isolate and cultivate muscle PC allowing to analyse functional properties considered important for signal generation and conduction.

METHODS

Pericytes were enzymatically isolated from hamster thigh muscles and further selected during a 16-30 days' cultivation period. PC markers were studied by fluorescence activated cell scanning (FACS) and immunocytochemistry. Electrical properties of the cultured PC were investigated by patch clamp technique as well as the membrane potential sensitive dye DiBAC(4) (3).

RESULTS

The cultured cells showed typical PC morphology and were positive for NG2, alpha smooth muscle actin, PDGFR-β and the gap junction protein Cx43. Expressions of at least one single or combinations of several markers were found in 80-90% of subpopulations. A subset of the patched cells expressed channel activities consistent with a Kv1.5 channel. In vivo presence of the channels was confirmed in sections of hamster thigh muscles. Interleukin-8, a myokine known to be released from exercising muscle, increased the expression but not the activity of this channel. Pharmacologic stimulation of the channel activity by flufenamic acid induced hyperpolarization of PC alone but not of endothelial cells [human umbilical vein endothelial cells (HUVEC)] alone. However, hyperpolarization was observed in HUVEC adjacent to PC when kept in co-culture.

CONCLUSION

We established a culture method for PC from skeletal muscle. A first functional characterization revealed properties which potentially enable these cells to generate hyperpolarizing signals and to communicate them to endothelial cells.

Men's issues: gender role conflict and substance abuse

The present paper aims to explore issues related to men within the context of seeking help for substance abuse. The male gender role is in conflict with help-seeking behaviour and with the fundamental principles of therapy, i.e. introspection, emotional expressivity and acknowledgement of difficulties. This creates a paradox for the male seeking psychological treatment and, it will be argued, particularly for the male substance abuser. It is argued that interventions which address the gender role and challenge men's perceptions of themselves are critical variables in the outcome of therapy, i.e. enabling them to make the necessary changes in order to promote psychological well-being. An examination of the male gender role in relation to intrapsychic issues and family systems will be followed by a brief discussion of therapeutic interventions. Some of the difficulties and issues confronted by workers who work with male substance abusers will be explored.

Dynamic factor analysis of groundwater quality trends in an agricultural area adjacent to Everglades National Park

The extensive eastern boundary of Everglades National Park (ENP) in south Florida (USA) is subject to one of the most expensive and ambitious environmental restoration projects in history. Understanding and predicting the water quality interactions between the shallow aquifer and surface water is a key component in meeting current environmental regulations and fine-tuning ENP wetland restoration while still maintaining flood protection for the adjacent developed areas. Dynamic factor analysis (DFA), a recent technique for the study of multivariate non-stationary time-series, was applied to study fluctuations in groundwater quality in the area. More than two years of hydrological and water quality time series (rainfall; water table depth; and soil, ground and surface water concentrations of N-NO3-, N-NH4+, P-PO4(3-), Total P, F-and Cl-) from a small agricultural watershed adjacent to the ENP were selected for the study. The unexplained variability required for determining the concentration of each chemical in the 16 wells was greatly reduced by including in the analysis some of the observed time series as explanatory variables (rainfall, water table depth, and soil and canal water chemical concentration). DFA results showed that groundwater concentration of three of the agrochemical species studied (N-NO3-, P-PO4(3-)and Total P) were affected by the same explanatory variables (water table depth, enriched topsoil, and occurrence of a leaching rainfall event, in order of decreasing relative importance). This indicates that leaching by rainfall is the main mechanism explaining concentration peaks in groundwater. In the case of N-NH4+, in addition to leaching, groundwater concentration is governed by lateral exchange with canals. F-and Cl- are mainly affected by periods of dilution by rainfall recharge, and by exchange with the canals. The unstructured nature of the common trends found suggests that these are related to the complex spatially and temporally varying land use patterns in the watershed. The results indicate that peak concentrations of agrochemicals in groundwater could be reduced by improving fertilization practices (by splitting and modifying timing of applications) and by operating the regional canal system to maintain the water table low, especially during the rainy periods.

Paying research participants: a study of current practices in Australia

OBJECTIVE

To examine current research payment practices and to inform development of clearer guidelines for researchers and ethics committees.

DESIGN

Exploratory email based questionnaire study of current research participant reimbursement practices. A diverse sample of organisations and individuals were targeted.

SETTING

Australia.

PARTICIPANTS

Contacts in 84 key research organisations and select electronic listservers across Australia. A total of 100 completed questionnaires were received with representations from a variety of research areas (for example, market, alcohol and drug, medical, pharmaceutical and social research).

MAIN MEASUREMENTS

Open-ended and fixed alternative questions about type of research agency; type of research; type of population under study; whether payment is standard; amounts and mechanisms of payment; factors taken into account when deciding on payment practices; and whether payment policies exist.

RESULTS

Reimbursement practice is highly variable. Where it occurs (most commonly for drug dependent rather than health professional or general population samples) it is largely monetary and is for time and out-of-pocket expenses. Ethics committees were reported to be often involved in decision making around reimbursement.

CONCLUSIONS

Research subject payment practices vary in Australia. Researchers who do provide payments to research participants generally do so without written policy and procedures. Ethics committees have an important role in developing guidelines in this area. Specific guidelines are needed considering existing local policies and procedures; payment models and their application in diverse settings; case study examples of types and levels of reimbursement; applied definitions of incentive and inducement; and the rationale for diverse payment practices in different settings.

Old Masters' lead white pigments: investigations of paintings from the 16th to the 17th century using high precision lead isotope abundance ratios

White lead (2PbCO(3).Pb(OH)(2)), a common component in 17c. artists' painting materials, was singled out to investigate the potential of lead isotope abundance ratios in the field of authentication and origin assignment. Paintings by Peter Paul Rubens, Anthony van Dyck and other Old Masters of the Northern and Southern schools were chosen for this study. An interdisciplinary approach was chosen using both analytical instrumental methods, art technological and art historical knowledge. Minute samples taken from paintings from selected art collections worldwide were investigated using mass spectrometry, scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDX). The high precision lead isotope abundance ratios were measured by multiple collector inductively coupled plasma mass spectrometry (MC-ICP-MS). The determination of the calcium matrix influence with respect to possible bias effects to the isotope ratios gave clear decision support, to whether a result lies within the stated combined measurement uncertainty of the result, to eliminate time-consuming matrix separations. The scatter plots of the measured isotope abundance ratios for the painting pigments from P. P. Rubens, A. van Dyck and other Flemish painters exhibit a very narrow distribution forming a cluster. The range of the measured ratio (206)Pb/(204)Pb amounts to 0.55% and for the ratio (207)Pb/(204)Pb to 0.2%. The comparison of the data to cis-alpine (Italian) sample pigments from paintings from the same time period reveals a clear distinction between the two fields. With respect to the lead isotope data originating from the ores it is assumed that the pigment isotope ratio distribution can be explained by very distinct origin of raw materials. Presumably, no mixing of different lead ores from Europe took place. The comparison of the measured white lead isotope ratio values (Flemish paintings) and the data from ore samples led to the unexpected conclusion that local ores were not used for the pigment production but British or German sources.

[Study of the quality of codification of diagnoses and procedures under DRG conditions]

A system based on Diagnosis Related Groups was introduced in Germany and is mandatory for hospitals from 2004. Hospitals, health care providers and the Medical Service of Social Security-Health Insurance (MDK) face a common effort. Proper codification of diagnoses and procedures is essential. The Medical Service in the State of Hessen, the Techniker Krankenkasse and the Burgerhospital Frankfurt am Main combined forces to assess codification under the DRG system.

GOALS

The partners cooperated to assess actual codification and to identify starting points for improvement.

METHODS

A random sample was taken from all in-patient cases (all departments) over a 6-month-period (n = 309). Codification or coding was checked according to German Coding Rules (Deutsche Kodierrichtlinien) from the complete hospital records. Different codification, or coding, was discussed between MDK and Hospital doctors.

RESULTS

The actual data revealed overcoding in 34 per cent of diagnoses and in 15 per cent of procedures. Undercoding was present in 9 per cent of diagnoses and in 2 per cent of procedures. The DRG grouping changed in 68 cases (22 per cent) after scrutiny by the Medical Service (MDK). The case-mix index (CMI) calculated from relative weights as coded by the hospital was 0.84. The case-mix index calculated from coding by MDK was 0.81. The CMI calculated from effective weights was 0.77 (hospital) and 0.75 (MDK).

DISCUSSION

Causes of faulty coding and possible remedies are presented.

CONCLUSIONS

Further systematic reviews are required to develop the DRG System and identify faulty trends.