Investigating survival, quality of life and cognition in PROton versus photon therapy for IDH-mutated diffuse grade 2 and 3 GLIOmas (PRO-GLIO): a randomised controlled trial in Norway and Sweden

INTRODUCTION

The use of proton therapy increases globally despite a lack of randomised controlled trials demonstrating its efficacy and safety. Proton therapy enables sparing of non-neoplastic tissue from radiation. This is principally beneficial and holds promise of reduced long-term side effects. However, the sparing of seemingly non-cancerous tissue is not necessarily positive for isocitrate dehydrogenase (IDH)-mutated diffuse gliomas grade 2-3, which have a diffuse growth pattern. With their relatively good prognosis, yet incurable nature, therapy needs to be delicately balanced to achieve a maximal survival benefit combined with an optimised quality of life.

METHODS AND ANALYSIS

PRO-GLIO (PROton versus photon therapy in IDH-mutated diffuse grade 2 and 3 GLIOmas) is an open-label, multicentre, randomised phase III non-inferiority study. 224 patients aged 18-65 years with IDH-mutated diffuse gliomas grade 2-3 from Norway and Sweden will be randomised 1:1 to radiotherapy delivered with protons (experimental arm) or photons (standard arm). First intervention-free survival at 2 years is the primary endpoint. Key secondary endpoints are fatigue and cognitive impairment, both at 2 years. Additional secondary outcomes include several survival measures, health-related quality of life parameters and health economy endpoints.

ETHICS AND DISSEMINATION

To implement proton therapy as part of standard of care for patients with IDH-mutated diffuse gliomas grade 2-3, it should be deemed safe. With its randomised controlled design testing proton versus photon therapy, PRO-GLIO will provide important information for this patient population concerning safety, cognition, fatigue and other quality of life parameters. As proton therapy is considerably more costly than its photon counterpart, cost-effectiveness will also be evaluated. PRO-GLIO is approved by ethical committees in Norway (Regional Committee for Medical & Health Research Ethics) and Sweden (The Swedish Ethical Review Authority) and patient inclusion has commenced. Trial results will be published in international peer-reviewed journals, relevant conferences, national and international meetings and expert forums.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05190172).

Pituitary Function after High-Dose 177Lu-DOTATATE Therapy and Long-Term Follow-Up

INTRODUCTION

The pituitary gland has a high expression of somatostatin receptors and is therefore a potential organ at risk for radiation-induced toxicity after 177Lu-DOTATATE treatment.

OBJECTIVE

To study changes in pituitary function in patients with neuroendocrine tumors (NETs) treated with dosimetry-based 177Lu-DOTATATE to detect possible late toxicity.

METHODS

68 patients from a phase II clinical trial of dosimetry-based, individualized 177Lu-DOTATATE therapy were included in this analysis. Patients had received a median of 5 (range 3-9) treatment cycles of 7.4 GBq/cycle. Median follow-up was 30 months (range 11-89). The GH/IGF-1 axis, gonadotropins, and adrenal and thyroid axes were analyzed at baseline and on a yearly basis thereafter. Percent changes in hormonal levels over time were analyzed statistically using a linear mixed model and described graphically using box plots. The absorbed radiation dose to the pituitary was estimated based on post-therapeutic imaging, and the results analyzed versus percent change in IGF-1 levels over time.

RESULTS

A statistically significant decrease in IGF-1 levels was found (p < 0.005), which correlated with the number of treatment cycles (p = 0.008) and the absorbed radiation dose (p = 0.03). A similar decrease, although non-significant, was seen in gonadotropins in postmenopausal women, while in men there was an increase during the first years after therapy, after which the levels returned to baseline. No change was observed in the adrenal or thyroid axes.

CONCLUSIONS

No signs of severe endocrine disorders were detected, although a significant decrease in the GH/IGF-1 axis was found, where dosimetric analyses indicated radiation-induced damage to the pituitary gland as a probable cause.

Prognostic implications of the expression levels of different immunoglobulin heavy chain-encoding RNAs in early breast cancer

The extent and composition of the immune response in a breast cancer is one important prognostic factor for the disease. The aim of the current work was to refine the analysis of the humoral component of an immune response in breast tumors by quantifying mRNA expression of different immunoglobulin classes and study their association with prognosis. We used RNA-Seq data from two local population-based breast cancer cohorts to determine the expression of IGJ and immunoglobulin heavy (IGH) chain-encoding RNAs. The association with prognosis was investigated and public data sets were used to corroborate the findings. Except for IGHE and IGHD, mRNAs encoding heavy chains were generally detected at substantial levels and correlated with other immune-related genes. High IGHG1 mRNA was associated with factors related to poor prognosis such as estrogen receptor negativity, HER2 amplification, and high grade, whereas high IGHA2 mRNA levels were primarily associated with lower age at diagnosis. High IGHA2 and IGJ mRNA levels were associated with a more favorable prognosis both in univariable and multivariable Cox models. When adjusting for other prognostic factors, high IGHG1 mRNA levels were positively associated with improved prognosis. To our knowledge, these results are the first to demonstrate that expression of individual Ig class types has prognostic implications in breast cancer.

Age and IQ Explained Working Memory Performance in a RCT with Fatty Fish in a Group of Forensic Inpatients

OBJECTIVES

To investigate the effect of a long-term fatty fish intervention on a pure cognitive mechanism important for self-regulation and mental health, i.e. working memory (WM), controlling for age and IQ.

DESIGN

A randomized controlled trial.

SETTING

A forensic facility.

PARTICIPANTS

Eighty-four young to middle aged male forensic inpatients with psychiatric disorders.

INTERVENTION

Consumption of farmed salmon or control meal (meat) three times a week during 23 weeks.

MEASUREMENT

Performance on WM tasks, both accuracy and mean reaction time, were recorded pre and post intervention.

RESULTS

Performance on a cognitive functioning tasks taxing WM seemed to be explained by age and IQ.

CONCLUSION

Fatty fish consumption did not improve WM performance in a group of young to middle aged adults with mental health problems, as less impressionable factors such as aging and intelligence seemed to be the key components. The present study improves the knowledge concerning the interaction among nutrition, health and the aging process.

Arsenic in seafood is associated with increased thyroid-stimulating hormone (TSH) in healthy volunteers - A randomized controlled trial

BACKGROUND

Exposure to exogenous elements like arsenic (As) may influence thyroid enzymes, thyroid-stimulating hormone (TSH), and the two principal thyroid hormones, free thyroxine (FT4) and free triiodothyronine (FT3), but little is known about how this is related to organic arsenicals, the main form in seafood.

AIM

To investigate whether a high intake of dietary arsenic from seafood can impact thyroid function and thyroid hormones by examining possible associations with changes in TSH, FT4, FT3 and the FT4:FT3-ratio in plasma.

METHODS

Thirty-eight healthy subjects were randomized into four groups. During a 14-day semi-controlled dietary study, the subjects ingested daily portions of either 150g cod, salmon, blue mussels or potato (control). Plasma concentrations of total As, FT3, FT4, TSH and selenium (Se), and urinary concentrations of iodine were monitored.

RESULTS

Plasma concentrations of TSH increased significantly in all seafood groups. The change in plasma As, with different coefficients for each seafood group, was the dominant factor in the optimal multiple regression model for change in TSH (R²=0.47). Plasma Se and iodine were negative and positive factors, respectively. There were also indications of changes in FT4, FT3 and the FT4:FT3 ratio consistent with a net inhibiting effect of As on FT4 to FT3 conversion.

CONCLUSION

Ingestion of seafood rich in various organic As species was strongly associated with an increase of the TSH concentrations in plasma. Change in TSH was positively associated with total plasma As, but varied with the type of seafood ingested. These findings indicate that organic dietary As, apparently depending on chemical form, may influence thyroid hormones and function.

Treatment Algorithm for Patients with Non-arthritic Hip Pain, Suspect for an Intraarticular Pathology

Background:

The amount of patients referred with longstanding, non-arthritic hip pain is increasing, as are the treatment options. Left untreated hip dysplasia, acetabular retroversion and femoroacetabular impingement (FAI) may lead to osteoarthritis (OA). Finding the right treatment option for the right patient can be challenging in patients with non-arthritic hip pain.

Purpose:

The purpose of this study was to categorize the radiographic findings seen in patients with longstanding hip pain, suspect for an intraarticular pathology, and provide a treatment algorithm allocating a specific treatment option for each clinical condition.

Material and Methods:

A review of the literature was performed using Public Medline searches of MeSH terms combined with synonyms for femoroacetabular impingement, acetabular retroversion, periacetabular osteotomy and hip arthroscopy.

Results:

Radiographic findings associated with acetabular retroversion described in the literature were the crossover sign, the posterior wall sign and the ischial spine sign, while Wiberg’s lateral center-edge angle (CE-angle) together with Leqeusne’s acetabular index indicate hip dysplasia. A Tönnis index >2 indicates osteoarthritis, however unsatisfying results are documented following joint preserving surgery with a Tönnis index >1. Furthermore, ischial spine sign in combination with the posterior wall sign indicates total acetabular retroversion prone to periacetabular osteotomy in contrast to focal retroversion prone to hip arthroscopy. These findings were used creating a treatment algorithm for intraarticular pathologies in patients with longstanding hip pain.

Conclusion:

Based on the radiographic findings, the algorithm presented in this study can be a helpful tool in the decision-making for the treatment of patients with non-arthritic hip pain, suspect for intraarticular pathologies.

Experimental proof of adjustable single-knob ion beam emittance partitioning

The performance of accelerators profits from phase-space tailoring by coupling of degrees of freedom. Previously applied techniques swap the emittances among the three degrees but the set of available emittances is fixed. In contrast to these emittance exchange scenarios, the emittance transfer scenario presented here allows for arbitrarily changing the set of emittances as long as the product of the emittances is preserved. This Letter is the first experimental demonstration of transverse emittance transfer along an ion beam line. The amount of transfer is chosen by setting just one single magnetic field value. The envelope functions (beta) and slopes (alpha) of the finally uncorrelated and repartitioned beam at the exit of the transfer line do not depend on the amount of transfer.

Die Diffusion von Spaltungs-Xenon aus Uranmetall

Die Diffusion von Xenon-133 aus neutronenbestrahltem, reaktor-reinem Uranmetall wurde im Temperaturbereich von 570 -1000° C untersucht. Der Diffusionsprozeß läßt sich mit einer Aktivierungsenergie von 2,6 eV/Atom (60 kcal/Mol) durch D = 2,4 · exp ( - 2,6/R T) cm2/s beschreiben.

Component-resolved in vitro diagnosis of carrot allergy in three different regions of Europe

BACKGROUND

Carrot is a frequent cause of food allergy in Europe. The objective of this study was to evaluate a panel of carrot allergens for diagnosis of carrot allergy in Spain, Switzerland and Denmark.

METHODS

Forty-nine carrot allergic patients, 71 pollen allergic but carrot-tolerant patients and 63 nonatopic controls were included. Serum IgE to carrot extract, recombinant carrot allergens (rDau c 1.0104; rDau c 1.0201; rDau c 4; the isoflavone reductase-like proteins rDau c IFR 1, rDau c IFR 2; the carrot cyclophilin rDau c Cyc) were analyzed by ImmunoCAP.

RESULTS

The sensitivity of the carrot extract-based test was 82%. Use of the recombinant allergens increased the sensitivity to 90%. The Dau c 1 isoforms were major allergens for Swiss and Danish carrot allergic patients, the profilin rDau c 4 for the Spanish patients. The rDau c IFR 1 and rDau c IFR 2 were recognized by 6% and 20% of the carrot allergics, but did not contribute to a further increase of sensitivity. Among pollen allergic controls, 34% had IgE to carrot extract, 18% to each of rDau c 1.0104, rDau c 1.0201 and rDau c 4, 8% to rDau c IFR 1 and 7% to rDau c IFR 2. Sensitization to rDau c Cyc occurred in one carrot allergic patient and one nonatopic control.

CONCLUSION

Component-resolved in vitro analyses revealed a significant difference in IgE sensitization pattern between geographical regions and in the prevalence of sensitization to carrot components between carrot allergic and carrot-tolerant but pollen sensitized patients.

Humans seem to produce arsenobetaine and dimethylarsinate after a bolus dose of seafood

Seafood is the predominant food source of several organoarsenic compounds. Some seafood species, like crustaceans and seaweed, also contain inorganic arsenic (iAs), a well-known toxicant. It is unclear whether human biotransformation of ingested organoarsenicals from seafood result in formation of arsenicals of health concern. The present controlled dietary study examined the urinary excretion of arsenic compounds (total arsenic (tAs), iAs, AB (arsenobetaine), dimethylarsinate (DMA) and methylarsonate (MA)) following ingestion of a single test meal of seafood (cod, 780 μg tAs, farmed salmon, 290 μg tAs or blue mussel, 690 μg tAs or potato (control, 110 μg tAs)) in 38 volunteers. The amount of ingested tAs excreted via the urine within 0-72 h varied significantly among the groups: Cod, 74% (52-92%), salmon 56% (46-82%), blue mussel 49% (37-78%), control 45% (30-60%). The estimated total urinary excretion of AB was higher than the amount of ingested AB in the blue mussel group (112%) and also ingestion of cod seemed to result in more AB, indicating possible endogenous formation of AB from other organoarsenicals. Excretion of iAs was lower than ingested (13-22% of the ingested iAs was excreted in the different groups). Although the ingested amount of iAs+DMA+MA was low for all seafood groups (1.2-4.5% of tAs ingested), the urinary DMA excretion was high in the blue mussel and salmon groups, counting for 25% and 11% of the excreted tAs respectively. In conclusion our data indicate a possible formation of AB as a result of biotransformation of other organic arsenicals. The considerable amount of DMA excreted is probably not only due to methylation of ingested iAs, but due to biotransformation of organoarsenicals making it an inappropriate biomarker of iAs exposure in populations with a high seafood intake.

Experimental evidence of space charge driven emittance coupling in high intensity linear accelerators

In high intensity linacs emittance exchange driven by space charge coupling may lead to the well-known "equipartitioning" phenomenon if the stop band at sigma(parallel) = sigma(perpendicular) is crossed at sufficiently slow rate. This Letter is the first experimental evidence of this phenomenon in a high intensity linear accelerator, here the UNILAC at GSI. Measurements of emittances at the entrance and exit of one drift tube linac tank comprising 15 lattice cells are taken for a set of transverse and longitudinal tunes. The onset of exchange on the stop band of previously derived "stability charts" confirms theoretical predictions. The measured transverse emittance growth also compares well with results from the beam dynamics simulation codes DYNAMION and TRACEWIN.

Digested Ara h 1 has sensitizing capacity in Brown Norway rats

BACKGROUND

Food allergies are a public health issue of growing concern, with peanuts in particular being associated with severe reactions. The peanut allergen, Ara h 1, belongs to the cupin plant food allergen family, which, unlike other structural families, appears to be broken down rapidly following gastrointestinal digestion.

OBJECTIVE

Using Ara h 1 as a model allergen, the ability of digested protein to sensitize has been investigated.

METHODS

Ara h 1 was purified from whole roasted peanuts. Intact Ara h 1 was digested in an in vitro model, simulating the human gastrointestinal digestion process. Digestion products were analysed for peptide sizes and their ability to aggregate. Brown Norway (BN) rats, used as an animal model, were immunized with purified intact Ara h 1 or the gastrointestinal digestion products thereof. The sensitizing capacity was evaluated by analyses of specific antibody (IgG1, IgG2a and IgE) responses and ability to trigger mediator release of rat basophilic leukaemia (RBL)-2H3 cells.

RESULTS

The present study showed that Ara h 1 was broken down, resulting in peptide fragments of sizes<2.0 kDa, of which approximately 50% was in aggregated complexes of Mr up to 20 kDa. Ara h 1 digesta were shown to have sensitizing capacity in BN rats, being capable of inducing specific IgG and IgE antibodies. The IgE response was functional, having the capacity to induce specific degranulation of RBL cells.

CONCLUSION

From this study, it can be concluded that lability of a food allergen to gastrointestinal digestion does not necessarily abrogate its allergenic sensitizing potential.

Experimental evidence of the 90 degrees stop band in the GSI UNILAC

In a particle accelerator with a periodic structure beam space charge force may excite resonant beam emittance growth if the particle's transverse phase advance approaches 90 degrees . A recent simulation study with the PARMILA code [D. Jeon, Phys. Rev. ST Accel. Beams 12, 054204 (2009)]10.1103/PhysRevSTAB.12.054204 has shown the feasibility of measuring the stop band of this fourth order resonance in the GSI Universal Linear Accelerator UNILAC and proposed its experimental verification, which is reported here. Measurements of transverse phase space distributions behind a periodically focusing structure reveal a fourfold symmetry characteristic of fourth order resonances as well as a resonance stop band above sigma_{0}=90 degrees per focusing cell. These experimental findings agree with results from three different beam dynamics simulation codes, i.e., DYNAMION, PARMILA, and TRACEWIN.

Differences in trabecular bone texture between knees with and without radiographic osteoarthritis detected by fractal methods

OBJECTIVE

To develop an accurate method for quantifying differences in the trabecular structure in the tibial bone between subjects with and without knee osteoarthritis (OA).

METHODS

Standard knee radiographs were taken from 26 subjects (seven women) with meniscectomy and radiographic OA Kellgren & Lawrence grade 2 or worse in the medial compartment. Each case knee was individually matched by sex, age, body mass index and medial or lateral compartment with a control knee. A newly developed augmented Hurst orientation transform (HOT) method was used to calculate texture parameters for regions selected in X-ray images of non-OA and OA tibial bones. This method produces a mean value of fractal dimensions (FD MEAN), FDs in the vertical (FDV) and horizontal (FDH) directions and along a direction of the roughest part of the tibial bone (FDSta), fractal signatures and a texture aspect ratio (Str). The ratio determines a degree of the bone texture anisotropy. Reproducibility was calculated using an intraclass correlation coefficient (ICC). Comparisons between cases and controls were made with paired t tests. The performance of the HOT method was evaluated against a benchmark fractal signature analysis (FSA) method.

RESULTS

Compared with controls, trabecular bone in OA knees showed significantly lower FD MEAN, FDV, FDH and FDSta and higher Str at trabecular image sizes 0.2-1.1mm (P<0.05, HOT). The reproducibility of all parameters was very good (ICC>0.8). In the medial compartment, fractal signatures calculated for OA horizontal and vertical trabeculae were significantly lower at sizes 0.3-0.55 mm (P<0.05, HOT) and 0.3-0.65 mm (P<0.001, FSA). In the lateral compartment, FDs calculated for OA trabeculae were lower than controls (horizontal: 0.3-0.55 mm (P<0.05, HOT) and 0.3-0.65 mm (P<0.001, FSA); vertical: 0.3-0.4mm (P<0.05, HOT) and 0.3-0.35 mm (P<0.001, FSA).

CONCLUSION

The augmented HOT method produces fractal signatures that are comparable to those obtained from the benchmark FSA method. The HOT method provides a more detailed description of OA changes in bone anisotropy than the FSA method. This includes a degree of bone anisotropy measured using data from all possible directions and a texture roughness calculated for the roughest part of the bone. It appears that the augmented HOT method is well suited to quantify OA changes in the tibial bone structure.

Determination of iodine in seafood by inductively coupled plasma/mass spectrometry

A method was developed for determination of total iodine content in different standard reference materials (SRMs) and seafood products by inductively coupled plasma/mass spectrometry (ICP/MS). If iodine is present as iodide and nitric acid is used in the wet digestion system, the observed signal is not stable when iodine is measured by ICP/MS at m/z 127. To stabilize the iodine signal, 3% ammonia solution (1 + 1, v/v) was added to the digest. The limit of quantitation of the method, defined as 6 times the standard deviation in the blank solution (n = 20) was estimated to be 15 mg/kg (using 0.2 g dry mass and a dilution factor of 50). The precision, expressed as repeatability of the iodine concentration, varied between 3.2 and 12% in SRMs, with concentrations of 4.70-0.17 mg/kg dry matter. The described method was compared with a method using tetramethylammonium hydroxide extraction. Both methods showed good precision and trueness by analyses of SRMs. The 2 methods were used to determine iodine in seafood from the Barents Sea, the Norwegian Sea, and the North Sea. The results showed great variation between different fish species as well as between individuals within a species. The lowest values of iodine were recorded in muscle of ling (Molva molva) with a mean of 0.07 mg/kg fresh weight and a variation between 0.03 and 0.11 mg/kg fresh weight. The highest values were found in cod (Gadus morhua) from the Barents Sea, with a mean of 2.5 mg/kg and a variation between 0.7 and 12.7 mg/kg fresh weight.

[Cases of measles in Denmark are caused by reintroduction of virus from abroad]

Measles vaccination was implemented in the child vaccination programme in Denmark in 1987 and produced a rapid decline in the incidence. Few cases were recorded annually until 1999. The measles virus isolated in Denmark during 1997-1998 was compared by partial sequencing of the haemagglutinin-coding region with Danish strains from the prevaccination era collected in 1965-1983, as well as with representatives of globally circulating strains of today. The dissimilarity of the prevaccination era strains identified in Denmark in 1997-1998 along with the similarity of these five strains with globally circulating strains at present, substantiate the conclusion that there is no persistent circulation of the measles virus in Denmark.

Impact of HIV-1 infection on VH3 gene repertoire of naive human B cells

B cells of the largest Ig variable heavy chain gene (VH) family, VH3, are reportedly decreased in patients with late stage HIV-1 disease. This deficit may contribute to their impaired responses to infections and vaccines. We confirmed that the VH3 family was underrepresented in serum IgM proteins, with a 45% decrease in patients with advanced HIV-1 disease. However, the proportion of VH3 within VH(1-6) IgM mRNA from peripheral B cells did not differ from that of control subjects (mean +/- SD, 57.1 +/- 9.7 vs 61.1 +/- 8. 7%). Similarly, within VH(1-6) IgD mRNA, which even more closely represents the unstimulated naive repertoire, the relative expression of VH3 mRNA was comparable in the two groups. Moreover, the frequency of individual genes within the VH3 family for IgD, particularly genes which encode putative HIV-1 gp120 binding sites, also was normal in HIV-1-infected patients. However, VH3 family expression for IgG mRNA was significantly decreased (17%) and VH4 IgG was increased (33%) relative to other VH families in advanced HIV-1-infected patients. Thus, the changes in VH family expression were more readily apparent in previously activated IgG "memory" B cell populations and, likely, in cells actively producing IgM rather than in resting naive cells. The presence of a relatively normal naive VH3 IgM and IgD mRNA repertoire in resting cells supports the prospect that with proper stimulation, particularly in conjunction with effective antiviral therapy, vigorous humoral immune responses to infections and vaccines may be elicited in this high-risk population.

Sequence analysis of the hemagglutinin gene of measles virus isolates in Denmark 1997-1998: no evidence of persistent circulation of measles virus in Denmark

The hemagglutinin-coding region of 17 virus samples from 12 measles cases in Denmark during 1997-1998 was analysed by partial nucleotide sequencing. The cases appeared as three sporadic cases and two epidemics, both with a limited time course and geographical distribution. The measles strains identified from the three sporadic cases and two epidemics could be allocated to five different previously well-defined sequence groups consistent with the assumption that cases of measles in Denmark are due to repeated introduction from abroad rather than persistent circulation of strains in the population.

Endothelial degradation of extracellular lyso-phosphatidylcholine

Formation of lysophospholipids, including lyso-phosphatidylcholine (lysoPC), is enhanced during oxidation of low-density lipoprotein, in ischaemic tissue and under inflammatory conditions. Besides being potentially cytotoxic, extracellular lysoPC induces changes in several properties of vascular endothelial cells. These include expression of endothelial adhesion molecules and interference with the endothelial production of nitrogen monoxide, prostacyclin and growth factors. One way of controlling the concentration of extracellular lysoPC is by the action of lysophospholipases, which degrade lysoPC into a free fatty acid and glycerophosphocholine. We therefore tested whether vascular endothelial cells have the ability to degrade extracellular lysoPC. Monolayers of primary cultures of human umbilical vein endothelial cells degraded an average of 84+/-24 nmol lysoPC/10(6) cells/2 h. By comparison, monocytes degraded 9.7+/-3.7 nmol lysoPC/10(6) cells/2 h, and erythrocytes and platelets < 1 nmol lysoPC/10(6) cells/2 h. The ability of endothelial cells to degrade extracellular phospholipids (diacylphosphatidyl choline) was found to be relatively low (9.5+/-6.4 nmol/10(6) cells/2 h). Triacylglycerol hydrolase activity was just above detection level. In conclusion, endothelial cells seem to degrade extracellular lysoPC effectively. This endothelial property may be important in controlling plasma and tissue levels of extracellular lysoPC as well as in the interaction between lysoPC and the vascular endothelium.

Strategies for increasing third-party reimbursement for nutrition counseling

OBJECTIVE AND SETTING

The purpose of this two-phase project was to determine whether specific interventions would affect third-party reimbursement for outpatient nutrition services at the Nutrition Clinic of the Los Robles Regional Medical Center.

DESIGN, SUBJECTS, AND INTERVENTION

In phase 1, the baseline reimbursement rate was determined by a questionnaire mailed to 191 clients seen in the clinic from January 1 to September 30, 1989. The survey was completed by 115 clients (60%). In phase 2, two strategies were used to increase reimbursement: instructing clients about how to file claims and providing clients with form letters of medical necessity to submit with their claims. The strategies were applied to 76 new clients from March 15 to July 31, 1991. Five weeks later, 67 of the 76 clients (88%) were interviewed by telephone.

OUTCOME MEASURES

The primary outcome measures were submission rates and reimbursement rates.

RESULTS

The results showed that in phase 1 (before intervention), 75 of the 115 clients surveyed (65%) submitted claims to their insurance carriers, and 12 of the 74 clients (15%) whose claims were acted on received reimbursement. In phase 2, 47 of the 67 clients (70%) submitted claims, and 15 of the 36 clients (42%) whose claims were acted on received reimbursement. Of the 20 clients who did not submit claims, 8 did not apply because of time constraints, and 5 did not apply because of low expectations of reimbursement.

APPLICATIONS/CONCLUSIONS

Form letters of medical necessity increased the reimbursement rate, but client instruction did not increase the submission rate. Most of the clients who did not submit a claim said they did not have time to do so. Therefore, the Nutrition Clinic is attempting to submit insurance forms for the clients after clients have paid for the consultation. Other providers of outpatient nutrition counseling who follow this strategy may increase the reimbursement rate.

Clinicians can agree in assessing relationship patterns in psychotherapy. The Core Conflictual Relationship Theme method

This study examines interjudge agreement on formulations of dynamic themes in psychotherapy, using a session-based method, namely, the Core Conflictual Relationship Theme. Agreement was assessed by two methods: one was based on themes that were tailor-made for each case, while the other was based on coding themes into a standard set of categories. To assess agreement on the tailor-made formulations, a paired-comparisons procedure was used. For a sample of 35 patients, the similarity ratings for matched cases were significantly higher than for purposely mismatched cases. Using the standard set of categories, agreement was also good; weighted kappa values ranged from .61 to .70. The results also demonstrate reliability for the location of the relationship episodes, which form the database for the Core Conflictual Relationship Theme. Our positive results suggest that this guided clinical method can be used reliably as a measure of relationship patterns in psychotherapy; our results provide the first moderate-sized sample demonstration of clinicians' agreement in formulating this complex concept.

The concentration of hyaluronate in amniotic fluid

The concentration of sodium hyaluronate has been determined in amniotic fluid by a specific radioassay. It shows a large individual variation. The mean concentration is approximately 20 micrograms/ml at Weeks 16-20 of the gestational period. It drops to approximately 1 micrograms/ml at Week 30 and is then constant until the end of the pregnancy.

Low renal papillary plasma flow in both Dahl and Kyoto rats with spontaneous hypertension

Abnormally low plasma flow to renal papilla characterizes Dahl hypertension. When eating a normal Na diet (0.3% NaCl) both hypertension-sensitive (S) rats and hypertension-resistant (R) rats, 16 weeks old, have fairly normal blood pressure (BP), averaging 144 and 129 mm Hg, respectively. However, even in this barely hypertensive state, 18 S rats had a 31% lower papillary plasma flow (Lilienfield method) than 22 R rats, 19.2 ml/100 g of papilla per min compared to 25.6 (P less than 0.001). When a high (8%) NaCl diet was fed for 7 days, R rats increased papillary plasma flow from 25.6 on 0.3% NaCl to 33.8 on 8% NaCl, a 32% rise (P less than 0.001). S rats increased papillary flow from 20.4 to 24.8, a 22% rise (P less than 0.05). When a high (8%) NaCl diet was fed for 4 weeks, R rats increased papillary plasma flow from 25.7 ml/100 g per min on 0.3% NaCl to 29.5 ml/100 g per min on 8% NaCl, a 15% rise (P less than 0.025). S rats increased papillary flow from 17.7 to 20.0 ml/100 g per min (not significant). S rats on 8% NaCl had a papillary flow 32% lower than R rats on 8% NaCl (P less than 0.001). BP of S rats rose to 162 mm Hg after 4 weeks on 8% NaCl; in R rats, BP did not rise at all. S rats on 0.3% NaCl have a low papillary flow even in a borderline hypertensive state. When challenged with 8% NaCl, R rats increased papillary flow, an adaptation possibly important for the natriuresis. S rats failed to achieve this same high papillary flow. Lacking this adaptation, hypertension may then conceivably occur in S rats to accomplish natriuresis through a "pressure natriuresis" mechanism. Papillary flow also decreased by 11% in 26 Kyoto 17-week-old spontaneously hypertensives (BP, 182 mm Hg) compared to 24 Kyoto normotensives (BP, 118 mm Hg), 29.5 vs 33.2 ml/100 g per min (P less than 0.001). Thus, low papillary flow exists in both hypertensions.