Modeling financial outcomes and quantifying risk in episode-based payment models

OBJECTIVES

Health systems and provider groups currently lack a systematic mechanism to evaluate the financial implications of value-based alternative payments. We sought to develop a method to prospectively quantify the financial implications, including risk and uncertainty of (1) transitioning from a fee-for-service to an episode-based payment model and (2) modifying episode-specific clinical cost drivers. Finally, we highlight practical applications for the model to help facilitate stakeholder engagement in the transition to value-based payment models.

STUDY DESIGN

We created a financial simulation from empirical data to demonstrate the feasibility and potential use cases within the context of a hypothetical episode-based payment model for prostate cancer surgery (prostatectomy).

METHODS

We used Monte Carlo simulation methods to predict financial outcomes under various clinical and payment model scenarios for our pilot prostatectomy episode use case. We input patient-level empirical cost, reimbursement, and clinical data for a cohort of 157 patients at our institution into our model to quantify expected financial outcomes (payments, financial margins) and financial risk for stakeholders (payer, hospital, providers) under an episode-based payment model.

RESULTS

Compared with the status quo, there is a range of expected financial outcomes for various stakeholders depending on the financial parameters (episode price, shared savings, downside risk, stop-loss) in an episode-based payment model. Modifying clinical cost drivers has a profound impact on these outcomes. Uncertainty is high due to the small number of episodes.

CONCLUSIONS

The simulation demonstrates that both financial parameters and clinical cost drivers significantly affect the expected financial outcomes for stakeholders in value-based payment models.

Cancer transcriptomic profiling from rapidly enriched circulating tumor cells

Transcriptomic profiling of metastatic cancer can illuminate mechanisms of progression and lead to new therapies, but standard biopsy is invasive and reflects only a single metastatic site. In contrast, circulating tumor cell (CTC) profiling is noninvasive and repeatable, reflecting the dynamic and systemic nature of advanced disease. To date, transcriptomic profiling of CTCs has not delivered on its full potential, because white blood cells (WBCs) vastly outnumber CTCs. Current profiling strategies either lack cancer sensitivity and specificity or require specialized CTC capture protocols that are not readily scalable to large patient cohorts. Here, we describe a new strategy for rapid CTC enrichment and transcriptomic profiling using commercially available WBC depletion, microfluidic enrichment and RNA sequencing. When applied to blood samples from patients with advanced prostate cancer (PC), transcriptomes from enriched samples cluster with cancer positive controls and previously undetectable prostate-specific transcripts become readily measurable. Gene set enrichment analysis reveals multiple significantly enriched signaling pathways associated with PC, as well as novel pathways that merit further study. This accessible and scalable approach yields cancer-specific transcriptomic data and can be applied repeatedly and noninvasively in large cancer patient cohorts to discover new therapeutic targets in advanced disease.

Sustained Growth of a University-Based Endocrine Surgery Program Over 10 Years

BACKGROUND

Endocrine surgery continues to mature as a subspecialty field. We describe the clinical performance of an academic endocrine surgery program (ESP) over its first 10 years.

METHODS

We examined all endocrine procedures performed during the 10-year period (2006-2015) following the inception of the ESP. Institutional and state-level data on case volume, patient geographic origin, and hospital-side costs were obtained.

RESULTS

Endocrine case volume increased by approximately ninefold over the study period (from 102 cases in 2006 to 919 cases in 2015). The rate of growth remained approximately linear, and was driven by geographic expansion of referral regions coupled with transitioning low- to moderate-acuity operations to venues outside of the main tertiary care hospital. Market share across the eight-county Southern California region grew by more than twofold over the study period. Increased utilization of outpatient surgery led to cost reductions, averaging 11.1% per case by 2015.

CONCLUSIONS

Establishment of an academic ESP can lead to sustained clinical growth and a fundamental shift in regional referral patterns. The nation's continued need for skilled high-volume endocrine surgeons represents opportunities for medical centers to institute their own dedicated endocrine surgery programs.

A Comparison of ToxCast Test Results with In Vivo and Other In Vitro Endpoints for Neuro, Endocrine, and Developmental Toxicities: A Case Study Using Endosulfan and Methidathion

INTRODUCTION

The U.S. Environmental Protection Agency's (EPA's) Toxicity Forecaster (ToxCast) is a potential tool for chemical prioritization, hazard identification, and risk assessment. We conducted a case study to compare ToxCast data with endpoints from other in vitro and in vivo studies for two data-rich pesticides: endosulfan and methidathion.

METHODS

ToxCast assays for endocrine disruption, development (zebrafish), and neurotoxicity were qualitatively compared to traditional neurotoxicity, developmental and reproductive toxicity findings. We also used in vitro-in vivo extrapolation to convert half-maximal activity concentrations in active ToxCast assays to rat oral equivalent doses, and quantitatively compared these to the lowest observable effect level (LOEL) from in vivo studies.

RESULTS

Endosulfan was inactive for GABAA R, unlike in vivo; but active with dopamine transporter assays and was neurotoxic in zebrafish as expected. Methidathion was not active for these endpoints in vivo or in vitro. Acetylcholinesterase inhibition was ToxCast-inactive, although both pesticides are inhibitors in vivo. ToxCast results were generally inactive for endosulfan estrogen receptor agonism and androgen receptor antagonism unlike in vivo. Calculated oral equivalent doses for estrogen receptor and androgen receptor pathways and for zebrafish assays for both compounds were generally consistent with in vivo LOELs. Endosulfan showed neurotoxicity and both pesticides showed developmental effects in the zebrafish assays, although methidathion is not developmentally toxic in vivo.

CONCLUSIONS

ToxCast's predictions showed concordance on some endpoints and nonconcordance, consisting mainly of false inactives, in several critical endpoints, likely due to a lack of metabolic activation and limitations in assay design. Zebrafish assays were good predictors of developmental toxicity and neurotoxicity for endosulfan.

Structural studies of the final enzyme in the alpha-aminoadipate pathway-saccharopine dehydrogenase from Saccharomyces cerevisiae

The 1.64 A structure of the apoenzyme form of saccharopine dehydrogenase (SDH) from Saccharomyces cerevisiae shows the enzyme to be composed of two domains with similar dinucleotide binding folds with a deep cleft at the interface. The structure reveals homology to alanine dehydrogenase, despite low primary sequence similarity. A model of the ternary complex of SDH, NAD, and saccharopine identifies residues Lys77 and Glu122 as potentially important for substrate binding and/or catalysis, consistent with a proton shuttle mechanism. Furthermore, the model suggests that a conformational change is required for catalysis and that residues Lys99 and Asp281 may be instrumental in mediating this change. Analysis of the crystal structure in the context of other homologous enzymes from pathogenic fungi and human sources sheds light into the suitability of SDH as a target for antimicrobial drug development.

Functional MR imaging of vision in the deaf

RATIONALE AND OBJECTIVES

Early loss of a sensory modality has been associated with cortical reorganization in both animal models and humans. The purpose of this study was to map visual activation with functional magnetic resonance (MR) imaging and to document possible developmental reorganization in the temporal lobe caused by early deafness.

MATERIALS AND METHODS

Six prelingual, profoundly deaf subjects were compared with a similar group of six hearing subjects. Three visual tasks were performed by both groups: attention to movement in the field-of-view periphery, shape matching, and mental rotation. Echo-planar coronal MR imaging was performed at 1.5 T.

RESULTS

Regions of interest encompassing the middle and posterior aspects of the superior and middle temporal gyri demonstrated a significantly (P < .05) increased activation in deaf subjects compared with hearing subjects, particularly on the right side (P < .05) and during the tasks involving motion. The most specific effect was noted during the mental-rotation task.

CONCLUSION

These results support the hypothesis that portions of the temporal lobe usually involved in auditory processing are more active during certain visual tasks in deaf compared with hearing subjects. Cortical reorganization may be an important factor in the deaf population when considering the physiology of temporal lobe lesions and predicting surgical outcomes. Functional MR imaging may be helpful during preoperative assessment in individuals with deafness.

Soluble E-cadherin is a valid prognostic marker in gastric carcinoma

BACKGROUND

Gastric cancer remains a major cause of cancer mortality globally but no good prognostic tumour marker is available. Soluble fragment of E-cadherin protein has been reported to increase in the sera of patients with cancer and recently was found to be elevated in 67% of patients with gastric cancer.

AIMS

To investigate if serum soluble E-cadherin is a valid prognostic marker in gastric cancer.

METHODS

Concentrations of soluble E-cadherin from 116 patients with histologically confirmed gastric adenocarcinoma and 40 healthy subjects were measured using an immunoenzymometric method with a commercially available sandwich ELISA kit based on monoclonal antibodies.

RESULTS

The logarithm of the means of soluble E-cadherin concentration was significantly higher in patients with gastric cancers (mean 3.85 (SD 0.28)) than in healthy subjects (3.71 (0.18)) (p=0.001), and in palliative/conservatively treated cancers (3.91 (0.35)) than in operable cancers (3.78 (0.19)) (p=0.015). The logarithm of the concentrations correlated with tumour size (p=0.032) and carcinoembryonic antigen concentrations (p=0.001). The cut off value calculated from discriminant analysis on operability and inoperability/palliative treatment was 7025 ng/ml. Soluble E-cadherin concentrations higher than this cut off value predicted tumour (T4) depth invasion (p=0.020, confidence interval (CI) 1.008-1.668) and palliative/conservative treatment (p=0.023, CI 1.038-2.514). In contrast, the relative risks for lymph node (N2) metastasis, distant metastasis, and stage III/IV disease were 1.41, 1.33, and 1.55 respectively, despite not reaching statistical significance.

CONCLUSION

Serum soluble E-cadherin is a potential valid prognostic marker for gastric cancer. A high concentration predicts palliative/conservative treatment and T4 invasion.

fMRI of auditory stimulation with intermolecular double-quantum coherences (iDQCs) at 1.5T

An intermolecular double-quantum coherence (iDQC) imaging technique was used to study auditory activation in the human brain at 1.5T with a dual temporal lobe surface phased array coil and a quadrature head coil. Preliminary results demonstrate that it is feasible to obtain auditory activation maps using iDQC imaging at 1.5T, both in individual subjects using the surface coil array and with multisubject averaging of data using the head coil. The most robust activation map was obtained when a spin-echo (SE) acquisition was combined with an iDQC excitation. Since SE with conventional single quantum coherence (SQC) and similar parameters showed much reduced activation in spite of its higher signal-to-noise ratio (SNR), it was determined that activation resulting from the SE-iDQC acquisition almost entirely originates from iDQCs. In addition, the fact that the robust activation was obtained using signals at an evolution time more sensitive to changes in magnetic susceptibilities also suggests the sensitivity of iDQCs to the BOLD effect upon activation. iDQCs provide a novel MRI method which is potentially more sensitive to the BOLD effect traditionally measured with SQC. Magn Reson Med 45:356-364, 2001.

Enhanced sensitivity to molecular diffusion with intermolecular double-quantum coherences: implications and potential applications

Apparent molecular self-diffusion rates for (1)H intermolecular double-quantum coherences (iDQCs) were measured in solvents covering a wide range of intrinsic diffusion coefficients at 1.5, 9.4 and 14T, and water iDQC diffusion-weighted images were obtained at 1.5T in human brains and at 9.4T in rat brains. Conventional single quantum coherence (SQC) measurements were also made in the same samples. Experimental results indicate that iDQCs are approximately twice as sensitive to diffusion as SQC. A general theoretical expression was derived, and a model was proposed to explain the phenomenon. Potential applications in DWI and brain fMRI were also discussed.

New image contrast mechanisms in intermolecular double-quantum coherence human MR imaging

We have developed a novel magnetic resonance imaging (MRI) method based on the intermolecular double-quantum coherence (DQC) in humans. Combined quantum mechanical and classical formalisms were used to characterize the signal and to aid in the design of a DQC imaging sequence with conventional or echoplanar acquisitions. Imaging contrast was evaluated in volunteers using a 1.5-T clinical scanner. The results demonstrated that the DQC images have contrasts fundamentally different from the conventional images based on single-quantum coherence (SQC). Both our theoretical analysis and experiments suggest that signals from DQCs have a higher signal-to-noise ratio than those from zero-quantum coherence (ZQC) for human brain imaging. The new contrast in DQC imaging may be useful for the detection of varying microstructures, potentially improving the detection of tumors without the need for contrast agents and providing a higher sensitivity and selectivity to magnetic susceptibility distributions in functional MRI brain studies.

Helicobacter pylori sero-prevalence in asthma

Asthma is a very common respiratory disease which is characterized by the presence of cytokine-mediated airway inflammation leading to smooth muscle contraction, oedema and progressive airway damage in some cases. In light of our recent finding of an increased sero-prevalence of Helicobacter pylori in bronchiectasis, we have determined serum levels of H. pylori-specific IgG in asthmatic and control subjects. Altogether 90 consecutive asthmatic [mean age +/- SD 42.6+/-16 years and 52 female (F)] and 97 healthy control subjects (mean age +/- SD 43.2+/-13.3 years and 51 female (F); P = 0.78 and 0.39 respectively) were recruited prospectively. H. pylori sero-prevalence was not significantly different between asthmatic and control subjects (P>0.05). Serum H. pylori IgG levels did not correlate with FEV1 % predicted, FVC % predicted or duration of asthma (P>0.05). Similar to the results of previously published sero-epidemiological studies, there was a weak correlation between serum H. pylori IgG with increasing age (r = 0.43, P = 0.004). Despite the sero-epidemiological association of H. pylori infection with many inflammatory conditions, our data showed no such association for middle age asthmatic patients with mild intermittent asthma in our locality.

In vivo intermolecular double-quantum imaging on a clinical 1.5 T MR scanner

A novel MRI method based on the intermolecular double-quantum coherence (DQC) for soft tissues is described. DQC images of human brain were obtained for the first time on a whole-body 1.5 T scanner. The combination of quantum and classical formalisms was used to characterize multiple-quantum coherences, and to aid in the design of a DQC imaging sequence. The theoretical analysis suggests that signals from the intermolecular DQCs have higher sensitivity than those from the zero-quantum coherence (ZQC) for human brain, and the sensitivity increases with increased field strength. The DQC signal may provide a new form of contrast for MRI.

Characteristics and pitfalls of contrast-enhanced, T1-weighted magnetization transfer images of the brain

RATIONALE AND OBJECTIVES

This study was undertaken to clarify the difference in signal pattern on contrast material-enhanced T1-weighted magnetic resonance (MR) magnetization transfer (MT) images between enhancing and nonenhancing lesions in various intracranial diseases and to determine the necessity of nonenhanced MT images for evaluating lesional contrast enhancement.

MATERIALS AND METHODS

MR images of 116 patients who underwent nonenhanced T1-weighted imaging, nonenhanced MT imaging, and contrast-enhanced MT imaging were reviewed. The increase in signal intensity of lesions relative to normal brain was compared between nonenhanced T1-weighted images and contrast-enhanced MT images. Signal intensity of lesions was compared with that of the striate nucleus and white matter on contrast-enhanced MT images. True enhancement was determined by comparison with nonenhanced MT images.

RESULTS

In all, 143 lesions, including 86 enhancing and 57 nonenhancing lesions, were identified among 63 patients. Almost all (99%) of the enhancing lesions were hyperintense to striate nucleus on contrast-enhanced MT images, and most (>87%) showed moderate to marked signal intensity increase from nonenhanced T1-weighted images to contrast-enhanced MT images. Most (>95%) of the nonenhancing lesions showed mild or no increase in relative signal intensity, and most (75%) were iso- or hypointense to striate nucleus on contrast-enhanced MT images. A few nonenhancing lesions (4%-6%), however, showed increase in signal intensity that was indistinguishable from true enhancement without comparison to non-enhanced MT images.

CONCLUSION

Nonenhanced MT images should be obtained to assess pathologic enhancement accurately.

Helicobacter pylori and upper gastrointestinal symptoms in bronchiectasis

The recently reported increase in seroprevalence of Helicobacter pylori, the causative pathogen in peptic ulceration, in bronchiectasis is unexplained. Therefore, the association of antibodies directed against cytotoxin-associated gene A(CagA), whose expression indicates virulence of H. pylori, and upper gastrointestinal symptoms in patients with stable bronchiectasis and healthy volunteers evaluated. One hundred patients (mean +/- SD age 55.1+/-16.7 yrs) and 94 healthy asymptomatic subjects (54.6+/-7.6 yrs) underwent clinical and physiological assessment and serum levels of anti-H. pylori CagA were determined using standard clinical and enzyme-linked immunosorbent assay techniques. Samples were positive for anti-H. pylori CagA in 11.7% of controls and 24% of bronchiectatic subjects (p = 0.03). There was, however, no association between serum H. pylori CagA immunoglobulin G level and forced expiratory volume in one second (FEV1), forced vital capacity (FVC), sputum volume, respiratory symptoms or upper respiratory gastrointestinal symptoms (p>0.05). Patients who suffered from acid regurgitation or upper abdominal distension had significantly lower FEV1 and FVC (as a percentage of the predicted value) compared to their counterparts. The results of anticytotoxin-associated gene A measurements in this study contrasted with the previous finding that anti-Helicobacter pylori immunoglobulin G correlated with sputum volume. These findings, therefore, suggest that Helicobacter pylori, should it have a pathogenic role in bronchiectasis, could act via noncytotoxin-associated gene A-mediated mechanisms, and, in this context, gastro-oesophageal reflux might be of importance in bronchiectasis.

Seroprevalence of cytotoxin-associated gene A positive Helicobacter pylori strains in Changle, an area with very high prevalence of gastric cancer in south China

BACKGROUND

Helicobacter pylori, especially the CagA-positive strains, are closely associated with peptic ulcers and gastric cancers. We performed a large scale gastric cancer screening project and examined the prevalence of H. pylori and CagA-positive strains in Changle, China, an area with one of the World's highest gastric cancer mortality. We also compared the prevalence with that in Hong Kong which has one-tenth of the gastric cancer mortality of that in Changle.

METHODS

A total of 2424 subjects in Changle and 523 subjects in Hong Kong had endoscopic examination and venesection. Sera were tested for anti-H. pylori antibody and anti-CagA antibody and correlated with endoscopic findings.

RESULTS

In Changle, 80. 9% of the subjects were H. pylori carriers. Out of 551 carriers, 408 (74%) were positive for anti-CagA antibody. A total of 76% and 87% of the asymptomatic and gastric cancer patients were positive for anti-CagA antibody, respectively (P > 0.05). Compared to Hong Kong, there was a significantly (P < 0.0001) higher prevalence of CagA-positive strains in asymptomatic subjects in Changle (76%) than in Hong Kong (28%), but not in peptic ulcers or gastric cancers.

CONCLUSIONS

Subjects in Changle had a high prevalence of H. pylori infection and a high prevalence of the CagA-positive strains. The contrast in the prevalence of CagA-positive strains, in asymptomatic subjects in two areas with differing gastric cancer mortality, supports the pathogenic role of CagA-positive strains in gastric carcinogenesis.

Differential Helicobacter pylori infection rates in two contrasting gastric cancer risk regions of South China. China Gastric Cancer Study Group

BACKGROUND

Carriers of Helicobacter pylori are believed to have a three- to six-fold increased risk of developing gastric cancer. We have recently conducted a simultaneous cross-sectional population study on the prevalence of H. pylori infection in a cohort of asymptomatic adult volunteers in two contrasting gastric cancer risk regions of South China, Hong Kong and Changle of Fujian. Their mean annual gastric cancer mortality has been approximately 7.5 and 75/100 000 population, respectively, since the beginning of the last decade. The aim of this study was to evaluate if H. pylori prevalence bears any relationship to gastric cancer mortality rates in these two southern regions of China.

METHODS

Sera were obtained from 397 volunteers in Hong Kong. They were tested for anti-H.pylori immunoglobulin (Ig) G antibody by using a commercial enzyme-linked immunosorbent assay (ELISA) kit. Volunteers of Changle (1456) had upper endoscopy examination and were also tested for anti-H. pylori IgG antibody by the same ELISA method.

RESULTS

The overall H. pylori infection prevalence was significantly higher in Changle (80.4%) than in Hong Kong (58.4%; P< 0.01). The high prevalence is associated with more atrophic gastritis. The overall risk of gastric cancer in people of Changle is approximately five-fold that of Hong Kong (adjusted odds ratio 4.9, 95% CI 2.5-9.8).

CONCLUSIONS

It is concluded that the prevalence of H. pylori infection rates bear a direct relationship to gastric cancer mortality rates in these two southern regions of China. Thus, H. pylori most likely plays a significant aetiopathogenetic role in gastric carcinogenesis in subjects living in Changle.

Corticosteroids and azathioprine do not prevent radiation-induced lung injury

The case of a man who presented with dyspnea and a dry cough six weeks after mediastinal radiotherapy for malignant thymoma is described. The patient was on prednisone (30 mg/day) and azathioprine (100 mg/day) throughout the course of radiation. The respiratory difficulties developed as the dose of prednisone was gradually decreased to 20 mg/day postradiation. Chest x-ray showed bilateral pulmonary infiltrates. Computed tomography scan of the thorax confirmed bilateral ground glass opacities, with well-defined lateral margin on the right side corresponding to the field of radiation. However, the airspace opacities extended beyond the radiation field into the periphery of the lungs together with mild airway dilation on the left side compatible with bronchiolitis obliterans organizing pneumonia (BOOP) or cryptogenic organizing pneumonia. Bronchoalveolar lavage performed on the nonirradiated area showed an intense lymphocytosis. No cause of BOOP other than radiation was found. Treatment with high dose corticosteroids (80 mg/day) resulted in rapid clinical and radiological improvement, and resolution of chest x-ray abnormalities. Focal mediastinal radiation therapy may induce diffuse lung injury including BOOP. In addition, the concurrent use of moderate dose prednisone and azathioprine during the periradiotherapy period does not prevent the development of either BOOP or classic radiation pneumonitis.

MR imaging of rabbit hip cartilage with a clinical imager and specifically designed surface coils

RATIONALE AND OBJECTIVES

The authors' purpose was to develop a magnetic resonance (MR) imaging technique for examining the hip joint of a rabbit with a clinical MR imager.

MATERIALS AND METHODS

Fourteen hips of 10 male New Zealand white rabbits were examined on a 1.5-T MR imager with a specially designed surface coil. Field of view was 3-8 cm, matrix was 256-512 x 192-256, section thickness was 0.9-2.0 mm, and spacing was 0.3-0.5 mm. The hips were sectioned and evaluated by means of light microscopy. Measurements of cartilage thickness from MR images were correlated with those from histologic specimens.

RESULTS

The resolution obtainable with a 1.5-T imager was adequate for imaging articular cartilage when a débrided rabbit hip specimen was placed in the center of a 3.5-cm single-loop coil. Rabbit hip cartilage had a trilaminar appearance on MR images. The coefficient of correlation between cartilage-thickness measurements was .81.

CONCLUSION

MR imaging of rabbit hip cartilage can be performed on 1.5-T clinical MR imaging unit. Limitations due to the field strength can be overcome with efficiently designed surface coils.

3D visual presentation of shoulder joint motion

The 3D visual presentation of biodynamic events of human joints is a challenging task. Although the 3D reconstruction of high contrast structures from CT data has been widely explored, then there is much less experience in reconstructing the small low contrast soft tissue structures from inhomogeneous and sometimes noisy MR data. Further, there are no algorithms for tracking the motion of moving anatomic structures through MR data. We represent a comprehensive approach to 3D musculoskeletal imagery that addresses these challenges. Specific imaging protocols, segmentation algorithms and rendering techniques are developed and applied to render complex 3D musculoskeletal systems for their 4D visual presentation. Applications of our approach include analysis of rotational motion of the shoulder, the knee flexion, and other complex musculoskeletal motions, and the development of interactive virtual human joints.

Prevalence of CagA-bearing Helicobacter pylori strains detected by the anti-CagA assay in patients with peptic ulcer disease and in controls

OBJECTIVE

Cytotoxin-associated gene (CagA)-bearing Helicobacter pylori strains have been associated with significant gastroduodenal pathologies. We have performed a study to evaluate the prevalence of CagA-bearing strains in a group of H. pylori-positive peptic ulcer disease and non-ulcer dyspepsia (NUD) patients, and healthy asymptomatic controls.

METHOD

Two hundred ninety-seven peptic ulcer disease, 45 NUD subjects, and 200 asymptomatic controls were studied. The newly developed anti-CagA antibody assay was used for the purpose of this study. The assay was performed by a conventional three-step enzyme-linked immunosorbent assay (ELISA) to detect the concentration of anti-CagA antibody present in the tested sera against the recombinant CagA 17/12 fusion protein. The final results were expressed with reference to a standard curve constructed from pooled CagA+ sera. Anti-CagA antibody assay reproducibility was assessed by intraplate and interplate variations.

RESULTS

The mean intraplate and interplate variations were 8.0% and 11.2%, respectively. Anti-CagA antibody was present in 165/197 (84%) duodenal ulcer disease, 80/100 (80%) gastric ulcer disease, 25/45 (55.6%) NUD subjects, and 29/100 (29%) asymptomatic controls. The ulcer disease subjects were significantly more likely than the NUD subjects and the asymptomatic controls to have a positive anti-CagA antibody assay ( p < 0.005 and p < 0.001, respectively). Moreover, the NUD subjects were more likely to be anti-CagA+ antibody than the asymptomatic controls (p < 0.005).

CONCLUSIONS

This newly developed anti-CagA antibody assay was highly reproducible. Anti-CagA antibody positivity was present in a significantly higher percentage of peptic ulcer disease subjects than in non-ulcer and asymptomatic healthy controls. Thus, anti-CagA antibody can be used as a clinical marker for peptic ulceration.

Evaluation of the renal arteries in kidney donors: value of three-dimensional phase-contrast MR angiography with maximum-intensity-projection or surface rendering

OBJECTIVE

Donors routinely undergo preoperative conventional arteriography to evaluate the renal arteries before nephrectomy. The purpose of this study was to assess the capability of three-dimensional phase-contrast MR angiograms postprocessed with maximum-intensity-projection and surface-rendering techniques to show the renal arteries of potential donors.

MATERIALS AND METHODS

Postprocessed three-dimensional phase-contrast MR angiograms of 17 patients were retrospectively reviewed by two experienced radiologists for the number and length of renal arteries visualized. Conventional arteriograms were used as the reference standard. Coronal maximum-intensity-projection and surface-rendered MR angiograms were also compared with each other with regard to the delineation of renal arteries from overlapping vessels.

RESULTS

MR angiograms showed all 34 single or dominant renal arteries but only eight of 10 accessory arteries seen on conventional arteriograms. One of the nonvisualized accessory arteries was located within the imaged volume, and the other one arose from the distal aorta beyond the imaged regions. Five of six arterial branches arising from the proximal 30-mm portions of the renal arteries were seen on MR angiograms. Postprocessing with either maximum-intensity projection or surface-rendering showed the same number of renal arteries, although surface rendering separated overlapping veins from the renal arteries better than the maximum-intensity-projection technique.

CONCLUSION

These results suggest that three-dimensional MR angiography is a reliable method of imaging single or dominant renal arteries, but not for showing all accessory renal arteries and small arterial branches. Surface rendering may provide specific advantages over maximum-intensity-projection in delineating renal arteries from overlapping vessels.

Out-of-plane motion compensation in multislice spin-echo MRI

In magnetic resonance imaging (MRI), it is well-known that patient motion plays a significant role in the degradation of image quality. Although the case of translational in-plane motion (x-y-motion) has been studied by several researchers, the effect of rigid, translational out-of-plane motion (z-motion) has not yet been completely analyzed due to its more complex nature. Out-of-plane motion introduces blurring along the slice-selection direction in addition to motion artifacts. Here, the authors present a model to represent the effect of out-of-plane motion on multislice MR data. The inversion of this model not only results in the correction of the artifacts due to out-of-plane motion, but also reduces blurring in the slice-selection direction, yielding higher resolution images. Because of the shift-varying nature of the authors' model, they propose to use a nonlinear postprocessing method, projection onto convex sets (POCS), for its inversion, provided that the motion kernel and the slice-selection profile are known. The proposed method has been tested on simulated data and then applied to actual MR data to demonstrate the feasibility of the technique in real imaging situations.

Flow compensation in MRI using a phase-corrected real reconstruction

Flow- and motion-related artifacts are problematic in clinical MR imaging. In this paper we discuss the utility of a phase-corrected real reconstruction to reduce flow artifacts. This technique is particularly useful when flow-compensation pulse sequences may not be possible, such as when a very short echo delay or small field-of-view is desired. We will demonstrate that the phase-corrected real reconstruction provides superior results to the magnitude reconstruction either used alone or in conjunction with existing flow-compensation techniques.

Temporomandibular joint: improved MR image quality with decreased section thickness

To determine if the quality of spin-echo magnetic resonance (MR) images of the temporomandibular joint (TMJ) could be improved by reducing section thickness, coronal and sagittal 3.0- and 1.5-mm MR images of the same joints were evaluated. Depiction of the disk, trabecular pattern, and cortex of the condyle was better on coronal 1.5-mm images than on 3.0-mm images (P less than .01), and 1.5-mm sagittal images were better for depiction of the trabecular pattern of the condyle than were 3.0-mm images (P less than .05). The ability of MR imaging with thinner sections to reveal more anatomic details should result in improved diagnostic accuracy.

Sensitivity of Bloom syndrome fibroblasts to mitomycin C

Lymphocytes and fibroblasts from people with Bloom syndrome, an autosomal recessive disorder associated with a predisposition to a wide variety of cancers, are known to be hypersensitive to ethylating agents as measured by sister chromatid exchange induction. Recently, hypersensitivity to cell killing by mitomycin C has also been reported in Bloom syndrome fibroblasts from three donors. We report here results which confirm the hypersensitivity of Bloom syndrome fibroblasts as measured by cell killing but show that they have a normal sensitivity to mitomycin C as measured by sister chromatid exchange induction. These results are discussed in terms of their relevance to the diversity of response of Bloom syndrome cells to mutagens, and the nature of the primary defect in Bloom syndrome.

Biosynthesis of chlorophyll b

Using [14C]chlorophyll a derived from a mutant of wheat lacking chlorophyll b, spinach thylakoids from very young leaves and cucumber thylakoids of irradiated, etiolated cotyledons convert chlorophyll a to b with apparent yields of 19% and 5%, respectively.