Heterologous Overexpression of Arabidopsis cel1 Enhances Grain Yield, Biomass and Early Maturity in Setaria viridis

Heterologous overexpression of Arabidopsis cellulase 1 (Atcel1) results in enhanced yield, early maturity, and increased biomass in dicotyledonous species like poplar and eucalyptus but has not been demonstrated in monocots. We produced transgenic Setaria viridis accession A10.1 plants overexpressing a monocotyledonous codon optimized (MCO) Atcel1. Agronomic characterization of the transgenic events showed that heterologous overexpression of MCOAtcel1 caused enhanced grain yield, shoot biomass, and accelerated maturation rate in the model grass species S. viridis under growth chamber conditions. The agronomic trait differences observed were consistent with previous reports in dicots but are here described in a monocot species and associated with increased seed yield. Overexpression of Atcel1 in S. viridis was shown to increase the number of panicles and seeds by 24-30%, enhance overall grain yield by up to 26%, and lead to a shoot dry biomass increase of 16-19%. Overexpression also reduced time to plant maturation and senescence by 12.5%. Our findings in S. viridis suggest that manipulation of Atcel1 has potential for developing early-maturing and higher-yielding monocotyledonous biomass crops suitable for climate-smart agriculture.

P14.79 Randomized phase II trial of Tumor Treating Fields plus radiation therapy plus temozolomide compared to radiation therapy plus temozolomide in patients with newly diagnosed glioblastoma

BACKGROUND

In last decade, there were numerous attempts to improve the outcome of patients with glioblastoma (GBM), but even after maximal surgical resection, radiation therapy (RT) and temozolomide (TMZ), followed by maintenance TMZ for 6 months the median OS is 14.6 months. In the EF-14 Phase III trial, the addition of Tumor Treating Fields (TTFields) at 200 kHz to maintenance TMZ increased the median OS to 20.9 months, compared with 16.0 months with maintenance TMZ alone (HR, 0.63; 95% CI, 0.53–0.76; p<0.001). Based on these results, the currently accepted standard of care for newly diagnosed GBM (ndGBM) is surgical resection if safely feasible, followed by RT with concomitant TMZ, and then followed by maintenance TMZ in combination with TTFields. Preclinical investigations have shown a radio-sensitizing effect of TTFields on glioma cells, suggesting synergistic effects between TTFields and radiotherapy. In a pilot study of 10 patients with ndGBM, we demonstrated that there was no increased treatment-related toxicity when TTFields were given in combination with RT/TMZ. The only TTFields-related adverse event was skin toxicity below the arrays. Preliminary progression free survival (PFS) data was encouraging. Based on the results of the pilot study, we designed this prospective, randomized Phase II study to further investigate if the addition of TTFields TMZ/RT treatment in ndGBM patients improves treatment efficacy and delays disease progression.

MATERIAL AND METHODS

Following debulking surgery or biopsy, 60 adult patients (≥18 years) with histologically confirmed GBM, KPS≥70 and life expectancy of at least 3 months will be randomized 1:1 to either a) RT with concomitant TMZ and TTFields (200 kHz) for 6 weeks followed by up to 6 months of maintenance TMZ in combination with TTFields (experimental arm) up to 24 months; or b) RT with concomitant TMZ alone followed by maintenance TMZ in combination with TTFields (control arm). Exclusion criteria: patients with early progressive disease, significant comorbidities precluding maintenance RT or TMZ or patients with an implanted electronic device. The primary endpoint is progression free survival at 12 months (PFS12). Treatment with TTFields will be continued until second progression or 24 months (the earlier of the two). All patients will be followed for survival. Grading and severity of all adverse events will be recorded using CTCAE V5.0. The sample size of 60 patients provides 80% power with a two-sided alpha level of 0.05 to detect a PFS12 of 46.5% with RT/TMZ/TTFields compared to 29.4% with RT/TMZ followed, respectively, by maintenance TMZ/TTFields (calculated from the RT/TMZ followed by maintenance TMZ/TTFields arm of the EF-14 trial). It is forecasted to take 24 months to fully recruit. Follow-up will continue for >12 months from recruitment of the last patient.

P14.71 Tumor Treating Fields combined with radiotherapy and temozolomide for newly diagnosed glioblastoma: final safety and efficacy results from a pilot study

BACKGROUND

Tumor Treating Fields (TTFields) are a non-invasive, loco-regional, anti-mitotic treatment consisting of low intensity alternating electric fields. The combination of TTFields with maintenance temozolomide significantly improved survival versus temozolomide alone in the phase 3 EF-14 study in newly diagnosed glioblastoma (ndGBM). In preclinical studies, TTFields increased the number of glioma cells undergoing cellular death following radiotherapy (RT) by inhibiting DNA damage repair, suggesting a radio-sensitizing effect of TTFields. This pilot study is the first to evaluate the safety and feasibility of administering TTFields concomitant to RT and TMZ in ndGBM patients.

MATERIAL AND METHODS

Patients diagnosed with ndGBM were treated with TTFields/RT/TMZ followed by maintenance TMZ and TTFields for up to 24 months. TTFields (200kHz) were delivered for >18 hours/day while the transducer arrays were removed during delivery of RT. TMZ was administered at a dose of 75 mg/m2/daily for 6 weeks and RT at a total dose of 60 Gy. The primary endpoint was safety of the combined TTFields/RT/TMZ; secondary endpoints included progression-free survival (PFS), overall survival (OS) and toxicity. Adverse events (AEs) were graded according to CTCAE V4.0.

RESULTS

10 ndGBM patients that recovered from maximal debulking surgery or biopsy were enrolled at a single center in Israel between April and December 2017. Five patients (50%) had undergone gross total resection while the rest had biopsy only. Eight of the patients were male, median age was 59, median KPS was 80 and median dose of RT was 60 Gy. Six patients (60%) reported at least one AE. The most common AE was TTFields-related skin toxicity, reported in four patients (40%), all of which were grade 1–2 in severity. Two patients reported serious AEs (seizures and general deterioration) that were considered unrelated to TTFields. Median PFS with RT/TMZ/TTFields was 10.5 months. Median OS has not yet been reached.

CONCLUSION

The proportion of patients with TTFields-related skin toxicity was similar to that reported in ndGBM patients in the randomized Phase III study (52%), where patients started TTFields at least 4 weeks after RT. No other TTFields-related toxicities were reported and there were no increase in RT- or TMZ-related toxicities as a result of combining TTFields with RT in addition to TMZ. Based on the safety and preliminary efficacy results of this pilot study, a phase II randomized study has been initiated to investigate the efficacy of concomitant RT/TMZ/TTFields in 60 ndGBM patients.

Arabidopsis Type III Gγ Protein AGG3 Is a Positive Regulator of Yield and Stress Responses in the Model Monocot Setaria viridis

Heterotrimeric G-proteins are key regulators of a multitude of growth and development pathways in eukaryotes. Along with the conserved G-protein components found in all organisms, plants have certain novel variants with unique architecture, which may be involved in the regulation of plant-specific traits. The higher plant-specific type III (or Class C) Gγ protein, which possesses a large C terminal extension, represented by AGG3 in Arabidopsis, is one such variant of canonical Gγ proteins. The type III Gγ proteins are involved in regulation of many agronomically important traits in plants, including seed yield, organ size regulation, abscisic acid (ABA)-dependent signaling and stress responses, and nitrogen use efficiency. However, the extant data, especially in the monocots, present a relatively complex and sometimes contradictory picture of the regulatory role of these proteins. It remains unclear if the positive traits observed in certain naturally occurring populations are due to the presence of specific allelic variants of the proteins or due to the altered expression of the gene itself. To address these possibilities, we have overexpressed the Arabidopsis AGG3 gene in the model monocot Setaria viridis and systematically evaluated its role in conferring agriculturally relevant phenotypes. Our data show that AtAGG3 is indeed functional in Setaria and suggest that a subset of the traits affected by the type III Gγ proteins are indeed positively correlated with the gene expression level, while others might have more complex, allele specific regulation.

Identifying the ideal profile of French yogurts for different clusters of consumers

Identifying the sensory properties that affect consumer preferences for food products is an important feature of product development. Different methods, such as external preference mapping or partial least squares regression, are used to establish relationships between sensory data and consumer preferences and to identify sensory attributes that drive consumer preferences, by highlighting optimum products. Plain French yogurts were evaluated by a sensory profiling method performed by 12 trained judges. In parallel, 180 consumers were asked to score their overall liking and complete a cognitive restraint questionnaire. After hierarchical cluster analysis on the liking scores, preference mapping using a quadratic regression model was performed. Five clusters of consumers were identified as a function of different preference patterns. Contrary to our expectations, fat levels were not discriminating. For each cluster, the results of preference mapping enabled the identification of optimum products. A comparison of the 5 sensory profiles revealed numerous differences between key sensory attributes. For example, one consumer cluster had a strong preference for products perceived as very thick, grainy, but with a less flowing texture, less sticky, whey presence and color, in contrast to other clusters. In addition, each segment of consumers was characterized according to the results of the cognitive restraint questionnaire.

Transarterial treatment with Onyx of intracranial dural arteriovenous fistula with cortical drainage in 17 patients

BACKGROUND AND PURPOSE

Intracranial DAVFs with cortical venous drainage have a high tendency to bleed. Complete closure of these lesions is essential to prevent clinically deleterious events. We describe our experience using Onyx in an arterial approach for treatment of DAVFs in 17 patients.

MATERIALS AND METHODS

Between 2006 and 2010, we used Onyx for performing transarterial embolization in 17 patients with intracranial DAVFs and cortical venous drainage. Clinical assessment was performed before and after every treatment at discharge and at follow-up. Fourteen patients underwent follow-up MR imaging and MRA, 8 of them also underwent follow-up diagnostic angiography.

RESULTS

Fifteen patients (88%) underwent 1 procedure. Complete obliteration by embolization with Onyx was achieved in 16 patients (94% acute obliteration). The mean amount of Onyx injected was 2.3 mL (range, 0.4-4.8 mL). The sole technical complication was an embolus to a branch of the MCA, which was resolved by intra-arterial tPA injection. A clinical complication of transient trochlear nerve palsy in the same patient due to mass effect of Onyx resolved spontaneously within 3 months.

CONCLUSIONS

Intra-arterial embolization of cranial DAVFs with cortical venous drainage by using Onyx results in a high rate of complete obliteration (94%) with low morbidity (6%). Follow-up DSA in 8 patients revealed no evidence of reopening.

Increased snow facilitates plant invasion in mixedgrass prairie

Although global change is known to influence plant invasion, little is known about interactions between altered precipitation and invasion. In the North American mixedgrass prairie, invasive species are often abundant in wet and nitrogen (N)-rich areas, suggesting that predicted changes in precipitation and N deposition could exacerbate invasion. Here, this possibility was tested by seeding six invasive species into experimental plots of mixedgrass prairie treated with a factorial combination of increased snow, summer irrigation, and N addition. Without added snow, seeded invasive species were rarely observed. Snow addition increased average above-ground biomass of Centaurea diffusa from 0.026 to 66 g m(-2), of Gypsophila paniculata from 0.1 to 7.3 g m(-2), and of Linaria dalmatica from 5 to 101 g m(-2). Given added snow, summer irrigation increased the density of G. paniculata, and N addition increased the density and biomass of L. dalmatica. Plant density responses mirrored those of plant biomass, indicating that increases in biomass resulted, in part, from increases in recruitment. In contrast to seeded invasive species, resident species did not respond to snow addition. These results suggest that increases in snowfall or variability of snowfall may exacerbate forb invasion in the mixedgrass prairie.

RTOG 0131: Phase II trial of pre-irradiation and concurrent temozolomide in patients with newly diagnosed anaplastic oligodendrogliomas and mixed anaplastic oligodendrogliomas: Relationship between 1p/19q status and progression-free survival

1517

Background: In a previous report, we showed in patients with newly diagnosed anaplastic oligodendrogliomas (AOs) and mixed anaplastic oligoastrocytomas (MAOs) that temozolomide (TMZ) can be given concurrently with radiation therapy (RT) with acceptable toxicity. We have now evaluated the efficacy of this regimen and correlated durability of response with tumor 1p/19q genotype. Methods: A phase II study was performed to evaluate the use of pre-RT TMZ followed by concurrent RT and TMZ in patients with newly diagnosed AO or MAO. The primary endpoint was to determine the pre-RT TMZ six-month progression rate, and secondary endpoints included progression-free survival and overall survival. Results: 40 eligible patients were entered into the trial. Thirty-two patients completed 6 months of pre-RT TMZ and concurrent RT and TMZ. Of the remaining eight patients, 4 withdrew due to toxicity and 4 other patients withdrew from study without evidence of toxicity or pre-RT progression. 1p/19q data are available in 37 cases; 23 tumors had loss of heterozygosity (LOH) of both 1p and 19q (double-deleted) while 14 tumors had LOH of either 1p or 19q (n = 3), or no LOH (n = 11). To date, 11 patients have experienced tumor progression; 1p/19q data are available for 10 of these cases (2 are double-deleted (2/23 = 9%), 8 have at least one intact chromosome (8/14 = 57%). Kaplan-Meier analysis demonstrates that progression free survival is significantly better for the double-deleted group (median time to progression not reached) than for the intact group (median time to progression = 15.2 months, p = 0.001). Overall survival is 98% (39/40) with a median follow-up of 17.5 months (2.8 - 31.1 months). Conclusions: LOH of both 1p and 19q is strongly correlated with a durable response of AO and MAO to a combined regimen of chemotherapy and radiation therapy. Tumors that are intact at 1p and/or 19q progress early despite an aggressive therapeutic regimen. These results suggest that future clinical trials should be prospectively stratified by tumor 1p/19q genotype.

[Table: see text]

A comparison of videotape and audiotape assessment of patient-centredness in family physicians' consultations

The aim of this study was to compare videotape and audiotape assessments of doctors' patient-centred behaviour in primary care consultations. The patient-centredness scale of Henbest and Stewart was used to measure the quality of 856 doctor-patient interactions in 258 consultations performed by 47 primary care physicians recorded on videotape. Assessments were performed once using only the sound track and a second time using both the sound and video-tracks. On a nominal quality scale of 0-3, the average score for all consultations was 1.94 (S.D. 0.63) by audio assessment, and 1.94 (S.D. 0.59) by video assessment (P<0.8). There was excellent agreement between audio and video scores over a wide range of scores. Little information (<5%) was lost when using audiotape compared to videotape. It was technically easier to assess the video recordings. Audio recording is equivalent to video recording for the assessment of patient-centredness using the scale of Henbest and Stewart in primary care consultations.

Leaving gatekeeping behind--effects of opening access to specialists for adults in a health maintenance organization

BACKGROUND

Gatekeeping refers to the prior approval of referrals to specialists by a primary care physician. Although many health plans view gatekeeping as an essential tool for controlling costs and coordinating care, many patients and physicians object to it.

METHODS

On April 1, 1998, Harvard Vanguard Medical Associates, a large, multispecialty, capitated group practice previously known as Harvard Community Health Plan, eliminated a gatekeeping system that had been in place for over 25 years. We determined the effects of opening access to specialists on visits to primary care physicians and specialists by adults. In randomly selected cohorts of 10,000 members each, we analyzed visits during 6-month periods for the 3 years before and 18 months after gatekeeping was eliminated.

RESULTS

Adults visited a primary care physician an average of 1.21 times and 1.19 times per six-month period before and after the elimination of gatekeeping, respectively (P=0.05); the average number of visits to a specialist was 0.78 per six-month period both before and after its elimination (P=0.35). There was little change in the percentage of visits to specialists included in the analysis as a proportion of all visits (39.1 percent before the elimination of gatekeeping and 39.5 percent afterward). The percentage of first visits to specialists as a proportion of all visits to specialists included in the analysis increased from 24.7 to 28.2 percent (P<0.001). There were small increases in the numbers of visits to orthopedists and physical or occupational therapists. The proportion of visits to specialists for low back pain that were new consultations increased from 26.6 to 32.9 percent (P=0.01).

CONCLUSIONS

In a capitated, multispecialty group practice, we found little evidence of substantial changes in the use of specialty services by adults in the first 18 months after the elimination of gatekeeping.

Market competition and patient-oriented research: the results of a national survey of medical school faculty

PURPOSE

To understand the effect of market competition on patient-oriented research at U.S. medical schools and teaching hospitals.

METHOD

From a multi-stage stratified, random sample, the authors surveyed 3,804 research faculty at 117 U.S. medical schools. The questionnaire assessed five variables, the type of research conducted by the respondent, changes in patient-oriented and non-clinical research in the preceding three years, amount of time spent on patient care, market stage of the respondent's institution, and research productivity.

RESULTS

Of the 2,336 faculty who responded (62%), 84% of those conducting patient-oriented research and 80% of those engaged in non-clinical research reported conducting the same amount of research or more in 1996-1997 than in the preceding three years. However, both patient-oriented and non-clinical researchers in the most competitive health care markets and those with high levels of patient care duties were most likely to report decreases in the amounts of such research conducted in the previous three years. Further, researchers reporting such decreases had been as productive in recent years and over their careers as had those who did not report a decrease.

CONCLUSIONS

This study provides additional evidence of the negative relationships that exist between high levels of market competition and patient care services on the patient-oriented and non-clinical research missions of teaching hospitals.

Modified order of allelic replication in lymphoma patients at different disease stages

Asynchronous replication of homologous loci was reported in lymphocytes of patients with lymphoma, ovarian and renal cancer as well as in lymphocytes of patients with premalignant conditions, for example, essential mixed cryoglobulinemia associated with hepatitis C virus and in monoclonal gammopathy of unknown significance. In the present study we evaluated the replication pattern in lymphocytes of four groups of patients with intermediate grade of non-Hodgkin lymphoma at various stages of their disease: 1) at diagnosis; 2) during cytotoxic treatment; 3) in remission; and 4) in relapse. A significantly higher proportion of the asynchronous pattern of replication at diagnosis, during cytotoxic treatment, and in relapse was noted as compared to healthy controls and to patients who achieved remission of their lymphoma. Also, the frequency of the two doublets (DD) pattern in every group studied was significantly lower than in the controls. If our findings can be confirmed in larger, long-term prospective studies, it may allow the use of a simple and inexpensive tool to closely observe patients with lymphoma who are at high risk for relapse.

Preparedness for clinical practice: reports of graduating residents at academic health centers

CONTEXT

Medical educators are seeking improved measures to assess the clinical competency of residents as they complete their graduate medical education.

OBJECTIVE

To assess residents' perceptions of their preparedness to provide common clinical services during their last year of graduate medical education.

DESIGN, SETTING, AND PARTICIPANTS

A 1998 national survey of residents completing their training in 8 specialties (internal medicine, pediatrics, family practice, obstetrics/gynecology, general surgery, orthopedic surgery, psychiatry, and anesthesiology) at academic health centers in the United States. A total of 2626 residents responded (response rate, 65%).

MAIN OUTCOME MEASURES

Residents' reports of their preparedness to perform clinical and nonclinical tasks relevant to their specialties.

RESULTS

Residents in all specialties rated themselves as prepared to manage most of the common conditions they would encounter in their clinical career. However, more than 10% of residents in each specialty reported that they felt unprepared to undertake 1 or more tasks relevant to their disciplines, such as caring for patients with human immunodeficiency virus/acquired immunodeficiency syndrome or substance abuse (family practice) or nursing home patients (internal medicine); performance of spinal surgery (orthopedic surgery) or abdominal aortic aneurysm repair (general surgery); and management of chronic pain (anesthesiology).

CONCLUSIONS

Overall, residents in their last year of training at academic health centers rate their clinical preparedness as high. However, opportunities for improvement exist in preparing residents for clinical practice.

Residents' preferences and preparation for caring for underserved populations

Access to care by low-income persons and residents of rural and poor inner-city areas is a persistent problem, yet physicians tend to be maldistributed relative to need. The objectives were to describe preferences of resident physicians to locate in underserved areas and to assess their preparedness to provide service to low-income populations. A national survey was made of residents completing their training in eight specialties at 162 US academic health center hospitals in 1998, with 2,626 residents responding. (Of 4,832 sampled, 813 had invalid addresses or were no longer in the residency program. Among the valid sample of 4,019, the response rate was 65%.) The percentage of residents ranking public hospitals, rural areas, and poor inner-city areas as desirable employment locations and the percentage feeling prepared to provide specified services associated with indigent populations were ascertained. Logistic regressions were used to calculate adjusted percentages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, and exposure to underserved patients during residency. Only one third of residents rated public hospitals as desirable settings, although there were large variations by specialty. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one quarter of respondents ranked rural (26%) or poor inner-city (25%) areas as desirable. Men (29%, P <.01) and noncitizen IMGs (43%, P <.01) were more likely than others to prefer rural settings. Residents who were more likely to rate poor inner-city settings as desirable included women (28%, P =.03), noncitizen IMGs (35%, P =.01), and especially underrepresented minorities (52%, P <.01). Whereas about 90% or more of residents felt prepared to treat common clinical conditions, only 67% of residents in four primary care specialties felt prepared to counsel patients about domestic violence or to care for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were more likely than men to feel prepared to counsel patients about domestic violence (70% vs. 63%, P =.002) and depression (83% vs. 75%, P <.01). Underrepresented minority residents were more likely than other residents to feel prepared to counsel patients about domestic violence (P <.01) and compliance with care (P =.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P =.01), substance abuse (P =.01), and to treat patients with HIV/AIDS (P =.01) or with substance abuse problems (P <.01). This study demonstrates the need to expose graduate trainees to underserved populations and suggests a continuing role of minorities, women, and noncitizen physicians in caring for low-income populations.

Status of clinical research in academic health centers: views from the research leadership

CONTEXT

The changing state of the health care system in the United States may be adversely affecting clinical research conducted in academic health centers (AHCs). Few formal data have been gathered about the nature and extent of the problems facing clinical research or the effects of remedies undertaken by AHCs.

OBJECTIVES

To assess the perceived quality and health of the clinical research enterprise and to determine challenges and adaptations to current environmental pressures.

DESIGN, SETTING, AND PARTICIPANTS

Mailed survey conducted between December 1998 and March 1999 of a subsample of department chairs and senior research administrators (SRAs) in all US medical schools. Of the 712 potential respondents, 478 completed a questionnaire, yielding an overall response rate of 67.1% (64.8% for SRAs and 67.8% for department chairs).

MAIN OUTCOME MEASURES

Ratings of overall health/robustness of clinical research, quality of research in 5 domains, extent of challenges to performing research, and sense of urgency in responding to research challenges; formal strategies for research-related tasks and their effects.

RESULTS

Slightly more than half (52%) of all respondents rated the health of the clinical research enterprise as good or excellent compared with 63% for nonclinical research (P<.001). Respondents were most likely to rate nonclinical research as high in quality (79%) compared with 70% for phase 3 clinical trials, 67% for translational research, 65% for phase 1 and 2 trials, and 57% for health services research (for all comparisons with nonclinical research, P<.001). Pressure on clinical faculty to see patients was perceived as a moderate-to-large problem for clinical research by the largest percentage of respondents (93%), followed by insufficient clinical revenues (89%), recruiting trained researchers (75%), lack of external support for clinical research (72%), competition from contract research organizations (48%), problems introduced by the institutional review board process (38%), and finding research participants (37%). In total, 81% of respondents considered the challenges facing clinical research in AHCs to be urgent or extremely urgent.

CONCLUSIONS

Academic leaders perceive clinical research activities in AHCs to be less healthy, of poorer quality, and facing greater challenges than nonclinical research activities. Many AHCs do not have policies or mechanisms to address challenges facing the clinical research mission. Even among those with such policies, more than half do not believe these policies have had large positive effects. Our findings support the view that the clinical research workforce and infrastructure may need to be expanded and strengthened to keep pace with advances in basic research.

Switching to gatekeeping: changes in expenditures and utilization for children

BACKGROUND

Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children.

OBJECTIVE

To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions.

DESIGN

We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions.

RESULTS

Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group.

CONCLUSION

Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.

Personal, organizational, and market level influences on physicians' practice patterns: results of a national survey of primary care physicians

BACKGROUND

One of the principal tenets of managed care is that physicians' clinical decisions can be influenced both to improve the quality and consistency of care and to decrease health care expenditures. Medical decision making, however, remains a complex phenomenon and the most important determinants of physicians' approaches to clinical decision making remain poorly understood.

OBJECTIVES

To determine how clinical decisions are associated with individual characteristics, practice setting and organizational characteristics, attributes of the patient population under care, and the market environment.

RESEARCH DESIGN

Cross-sectional, nationally representative survey of patient-care physicians.

SUBJECTS

Primary care physicians who provide direct patient care at least 20 hours per week.

MEASURES

Proportion of physicians who would order a referral, diagnostic test, or treatment for 5 clinical scenarios thought to be representative of discretionary medical decisions.

RESULTS

Responses were received from 4,825 primary care physicians who cared for adult patients (Response Rate 65%). The distribution of results for each of the five clinical scenarios demonstrates significant variability both within and between physicians. No evidence was seen of a consistent practice style across the vignettes (eg, "aggressive" or "conservative"). The organizational setting of practice was the most consistent predictor of behavior across all the clinical scenarios, with the exception of back pain, which was minimally related to any of the environmental factors. When compared to physicians in solo practice, physicians in all other practice settings were less likely to order a test or referral or pursue treatment. Practice involvement with managed care and measures of financial influences and administrative strategies associated with managed care were minimally and inconsistently associated with reported physician behaviors.

CONCLUSIONS

The ability of managed care to improve the quality and consistency of care while also controlling the costs of care depends on its ability to influence medical decisions. Our findings generally demonstrate that managed care has a weak influence on discretionary medical decisions and that the influence of managed care pales in comparison to personal and practice setting influences.

Physicians' assessments of their ability to provide high-quality care in a changing health care system

BACKGROUND

With the growth of managed care, there are increasing concerns but inconclusive evidence regarding deterioration in the quality of medical care.

OBJECTIVES

To assess physicians' perceptions of their ability to provide high-quality care and explore what factors, including managed care, affect these perceptions.

RESEARCH DESIGN

Bivariate and multivariate analyses of the Community Tracking Study Physician Survey, a cross-sectional, nationally representative telephone survey of 12,385 patient-care physicians conducted in 1996/1997. The response rate was 65%.

PARTICIPANTS

Physicians who provide direct patient care for > or =20 h/wk, excluding federal employees and those in selected specialties.

MEASURES

Level of agreement with 4 statements: 1 regarding overall ability to provide high-quality care and 3 regarding aspects of care delivery associated with quality.

RESULTS

Between 21% and 31% of physicians disagreed with the quality statements. Specialists were generally 50% more likely than primary care physicians to express concerns about their ability to provide quality care. Generally, the number of managed care contracts, but not the percent of practice revenue from managed care, was negatively associated with perceived quality. Market-level managed care penetration independently affected physicians' perceptions. Practice setting affected perceptions of quality, with physicians in group settings less likely to express concerns than physicians in solo and 2-physician practices. Specific financial incentives and care management tools had limited positive or negative associations with perceived quality.

CONCLUSIONS

Managed care involvement is only modestly associated with reduced perceptions of quality among physicians, with some specific tools enhancing perceived quality. Physicians may be able to moderate some negative effects of managed care by altering their practice arrangements.

A report card on quality improvement for children's health care

OBJECTIVE

Improving the quality of health care is a national priority. Nonetheless, no systematic effort has assessed the status of quality improvement (QI) initiatives for children or reviewed past research in child health care QI. This assessment is necessary to establish priorities for QI programs and research.

METHODS

To assess the status of QI initiatives and research, we reviewed the literature and interviewed experts experienced in QI for child health services. We defined QI as activities intended to close the gap between desired processes and outcomes of care and what is actually delivered. We classified reports published between 1985 and 1997 by publication characteristics, study design, clinical problem addressed, site of intervention, the QI method(s) used, and explicit association with a continuous quality improvement program.

RESULTS

We reviewed 68 reports meeting our definition of QI. More than half (48) were published after 1994. The reviewed reports included controlled evaluations in 36% of all identified interventions, and 3% of the reports were associated with continuous quality improvement. QI methods demonstrating some effectiveness included reminder systems for office-based preventive services and inpatient pathways for complex care. Reportedly successful QI initiatives more commonly described improvement in administrative measures such as rate of hospitalization or length of stay rather than functional status or quality of life. Interviews found that barriers to QI for children were similar to those for adults, but were compounded by difficulties in measuring child health outcomes, limited resources among public organizations and small provider groups, and relative lack of competition for pediatric tertiary care providers. Research and dissemination of QI for children were seen as less well developed than for adults.

CONCLUSIONS

Attempts to improve the quality of child health services have been increasing, and the evidence we reviewed suggests that it is possible to improve the quality of care for children. Nonetheless, numerous gaps remain in the understanding of QI for children, and widespread improvement in the quality of health services for children faces significant barriers.

Understanding the relationship between market competition and students' ratings of the managed care content of their undergraduate medical education

PURPOSE

The increase in managed care has led to questions about the inadequacy of instruction undergraduate medical students receive in curricular areas related to managed care. This study examined (1) the percentages of graduating medical students who felt they had received inadequate instruction in six curricular content areas (CCAs): primary care, care of ambulatory patients, health promotion and disease prevention, medical care cost control, teamwork with other health professionals, and cost-effective medical practice; and (2) whether the market competitiveness of these students' medical schools affected their reports of inadequacy of instruction in these CCAs.

METHOD

Data from the Association of American Medical Colleges' Graduation Questionnaires (GQs) from 1994 to 1997 were analyzed. The GQ asked graduating students to rate the adequacy of instruction they had received in the six CCAs. Students' ratings were collapsed into the dichotomous variables "inadequate" and "not inadequate." The market competitiveness of medical schools was determined using the four-stage Market Evolution Model developed by the University HealthSystem Consortium. Only responses from students graduating from medical schools that could be staged for all four years of the study were analyzed. Statistical analyses were performed to determine trends for each CCA by year, across the entire study period, by market stage, and by market stage across the entire study period.

RESULTS

A total of 39,136 respondents from 86 medical schools were used in the study. The percentages of graduating medical students who reported inadequate instruction decreased over the study period for five of the six CCAs: primary care (27.6% in 1994 to 13.7% in 1997), ambulatory care (37.4% to 23. 9%), medical care cost control (62.9% to 52.9%) cost-effectiveness of medical practice (62.7% to 53.9%), and health promotion and disease prevention (44.4% to 23.7%); all at p <0.001. The responses for inadequacy of instruction for teamwork with other health professionals remained steady from 1994 to 1996 (10.2% to 10.6%), then increased 21.8% in 1997. Over the course of the study, students graduating from schools in more competitive markets (Stage 3 or Stage 4) were more likely to report inadequate instruction in three CCAs, primary care, ambulatory care, and health promotion and disease prevention, than were those graduating from schools in less competitive markets (Stage 1 and Stage 2). Conversely, students graduating from schools in the more competitive health care markets were less likely to report inadequate instruction in cost-effectiveness and cost control than were students from schools in less competitive markets.

CONCLUSION

Graduating students' reports of inadequacy of instruction decreased over the study period for five of the six CCAs, increasing only for teamwork with other professionals. Findings were mixed with regard to the relationship of medical schools' market competitiveness and graduating students' reports of inadequacy of instruction. More research is needed to confirm graduating students' perceptions of the inadequacy of their instruction in CCAs related to managed care, particularly once they have gained experience treating patients in managed care environments.

Prenatal diagnosis of trisomy 4 mosaicism

Trisomy 4 mosaicism is rare. To our knowledge only two cases of prenatally diagnosed trisomy 4 mosaicism have been reported. One case resulted in a normal liveborn male, the other resulted in an abnormal liveborn female. The karyotype of our case at the time of amniocentesis was 47,XY,+4[3]/ 46,XY[33] and resulted in a normal liveborn male. FISH analysis using an alpha satellite chromosome 4 probe was performed to confirm the cytogenetic findings. Follow-up chromosome analysis of cord blood, peripheral blood, foreskin, and umbilical cord fibroblasts showed a normal 46,XY male karyotype in all cells. FISH analysis of cord blood, umbilical cord fibroblasts, and amniotic fluid cells demonstrated two signals in 246 nuclei (i.e., 46,XY) and three signals in six nuclei (i.e., 47,XY,+4). Here we describe the present case of trisomy 4 mosaicism, the literature is reviewed, and the significance of this finding is discussed.

Academic Industry Relationships in Biotechnology: A Primer on Policy and Practice

Academic industry relationships (AIRs) in biotechnology are part of the modern life science economy. They cannot and should not be prevented. But their benefits should not be exaggerated, nor their risks minimized or ignored. It is essential that these relationships be understood, monitored, and managed in a manner that protects the investments and the integrity of involved individuals, institutions, and science in general. Failure to do so could result in loss of public confidence and support for research enterprise--a priceless resource whose integrity and independence are critical to the future of the scientific endeavor.

A tale of two systems: the changing academic health center

Major changes in academic health centers (AHCs) may not be confined to the United States. Both Partners HealthCare System in Boston and University College London School of Medicine/University College Hospital Trust in London have recently undergone mergers, downsizing, and cost cutting on unprecedented scales. A comparison of the recent histories of these eminent AHCs reveals striking similarities in the clinical and academic pressures bearing down upon them and in their responses. It also reveals important differences in their situations and actions, traceable in large part to the contrasting roles of governments and markets in the health care economies of these two countries.