What is Comprehensive Geriatric Assessment (CGA)? An umbrella review

Background

Comprehensive Geriatric Assessment (CGA) is now the accepted gold standard for caring for frail older people in hospital. However, there is uncertainty about identifying and targeting suitable recipients and which patients benefit the most.

Objectives

our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA.

Methods

we used the Joanna Briggs Institute umbrella review method. We searched for systematic reviews and meta-analyses describing CGA services for hospital inpatients in the Cochrane Database of Systematic Reviews, Database of Reviews of Effectiveness (DARE), MEDLINE and EMBASE and a range of other sources.

Results

we screened 1,010 titles and evaluated 419 abstracts for eligibility, 143 full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. The most widely used definition of CGA was: 'a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs'. Key clinical outcomes included mortality, activities of daily living and dependency. The main beneficiaries were people ≥55 years in receipt of acute care. Frailty in CGA recipients and patient related outcomes were not usually reported.

Conclusions

we confirm a widely used definition of CGA. Key outcomes are death, disability and institutionalisation. The main beneficiaries in hospital are older people with acute illness. The presence of frailty has not been widely examined as a determinant of CGA outcome.

New horizons in comprehensive geriatric assessment

In this article, we discuss the emergence of new models for delivery of comprehensive geriatric assessment (CGA) in the acute hospital setting. CGA is the core technology of Geriatric Medicine and for hospital inpatients it improves key outcomes such as survival, time spent at home and institutionalisation. Traditionally It is delivered by specialised multidisciplinary teams, often in dedicated wards, but in recent years has begun to be taken up and developed quite early in the admission process (at the 'front door'), across traditional ward boundaries and in specialty settings such as surgical and pre-operative care, and oncology. We have scanned recent literature, including observational studies of service evaluations, and service descriptions presented as abstracts of conference presentations to provide an overview of an emerging landscape of innovation and development in CGA services for hospital inpatients.

Identification of a small-molecule inhibitor of Stat5a/b through structure-based screen for therapy development for prostate cancer

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Background: There are no effective treatments for metastatic or castration resistant prostate cancer. We have shown that transcription factor Stat5a/b is constitutively active in high-grade prostate cancer, but not in normal human prostate epithelium. Stat5a/b is active in 95% of clinical castration resistant prostate cancers, and the expression of active Stat5a/b in primary prostate cancer predicts early disease recurrence. Stat5a/b is critical for the viability of prostate cancer cells in vitro and for growth of prostate xenograft tumors in nude mice. Stat5a/b synergizes with androgen receptor (AR) and Stat5a/b promotes metastatic behavior of human prostate cancer cells in vitro and in vivo. Here, we hypothesize that Stat5a/b is a molecular target for rational drug design for prostate cancer.

Methods: We identified a small- molecule inhibitor of Stat5a/b dimerization by structure-based virtual screen from a database of 30 million chemical structures. The efficacy of the Stat5a/b inhibitor was determined by reporter gene assays, dimerization by co-immunoprecipitations, nuclear translocation by cytochemistry and binding to DNA by EMSA. Cell viability was analyzed by MTT assay.

Results: The novel Stat5a/b inhibitor IST5-002 inhibited transcriptional activity of Stat5a/b at IC50 of 1.5 μ M for Stat5a and 3.5 μ M for Stat5b, but not of Stat3 in prostate cancer cells. IST5-002 inhibited dimerization, nuclear translocation, and binding of Stat5a/b to the Stat5 DNA consensus sequence. Furthermore, IST5-002 inhibited expression of Stat5a/b target gene cyclin D1, and induced massive apoptosis of DU145, CWR22Rv1 and LNCaP human prostate cancer cells. IST5-002 blocked prostate cancer xenograft tumor growth in nude mice and induced death in clinical prostate cancers ex vivo in 3D organ cultures.

Conclusions: We have identified a small molecule Stat5a/b inhibitor IST5-002 for therapy development for prostate cancer. Future work will focus on chemical modifications of IST5-002 to achieve IC50 below 1 μ M and oral administration.

No significant financial relationships to disclose.

Moderate exercise attenuates caspase-3 activity, oxidative stress, and inhibits progression of diabetic renal disease in db/db mice

Diabetic nephropathy, the leading cause of end-stage renal disease, is characterized by a proapoptotic and prooxidative environment. The mechanisms by which lifestyle interventions, such as exercise, benefit diabetic nephropathy are unknown. We hypothesized that exercise inhibits early diabetic nephropathy via attenuation of the mitochondrial apoptotic pathway and oxidative damage. Type 2 diabetic db/db and normoglycemic wild-type mice were exercised for an hour everyday at a moderate intensity for 7 wk, following which renal function, morphology, apoptotic signaling, and oxidative stress were evaluated. Exercise reduced body weight, albuminuria, and pathological glomerular expansion in db/db mice independent of hyperglycemic status. Changes in renal morphology were also related to reduced caspase-3 (main effector caspase in renal apoptosis), caspase-8 (main initiator caspase of the "extrinsic" pathway) activities, and TNF-alpha expression. A role for the mitochondrial apoptotic pathway was unlikely as both caspase-9 activity (initiator caspase of this pathway) and expression of regulatory proteins such as Bax and Bcl-2 were unchanged. Kidneys from db/db mice also produced higher levels of superoxides and had greater oxidative damage concurrent with downregulation of superoxide dismutase (SOD) 1 and 3. Interestingly, although exercise also increased superoxides, there was also upregulation of multiple SODs that likely inhibited lipid (hydroperoxides) and protein (carbonyls and nitrotyrosine) oxidation in db/db kidneys. In conclusion, exercise can inhibit progression of early diabetic nephropathy independent of hyperglycemia. Reductions in caspase-3 and caspase-8 activities, with parallel improvements in SOD expression and reduced oxidative damage, could underlie the beneficial effects of exercise in diabetic kidney disease.

An investigational rapid RT-PCR assay for the detection of metastasis in sentinel lymph nodes shows improved performance over frozen section H&E: Analysis by primary tumor characteristics

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Background: In order for a RT-PCR test to accurately diagnose the metastatic status of sentinel lymph nodes the test must perform well across all primary tumor types. Methods: A prospective study was conducted at 11 clinical sites to evaluate a real- time RT-PCR assay (investigational GeneSearch™ Breast Lymph Node Assay, Veridex, LLC, Warren, NJ, USA) for the detection of sentinel lymph node metastasis in patients with invasive breast cancer. Detection limits were pre-set to detect only metastases that are clinically relevant (> 0.2 mm). Tumor information such as tumor stage, size, type and other molecular characteristics were collected. RT-PCR assay was then compared against permanent section H&E and IHC for final performance calculations. A total of 416 patients’ results were analyzed for overall assay performance: sensitivity 87.6% and specificity 94.2%. The assay was then evaluated within each primary tumor characteristics category. Results: Overall RT-PCR sensitivity is an improvement (p= 0.039) over that of current intra-operative methods (frozen section H&E), while specificity is similar (p=0.054). For the various tumor sub-types, in a matched dataset, the RT-PCR assay has up to 35.7% (Invasive Lobular) higher sensitivity compared to frozen section H&E. Conclusions: The data suggest that the RT-PCR assay performs well and has higher sensitivity than frozen section H&E regardless of primary tumor characteristics and, therefore, can be used to detect metastasis for all types of invasive breast cancer.

[Table: see text]

No significant financial relationships to disclose.

Biomarker analysis by breast cancer phenotype in African-American versus Caucasian patients: Correlates with survival

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Background: Breast carcinomas in African-American (AA) patients (pts) have poorer prognosis and higher likelihood of aggressive basal phenotype (triple negative for ER, PR, HER2) than those in Caucasian (C) patients (Carey et al, JAMA 2006, 295(21):2492; Morris et al, Breast Cancer Res Treat 2006, abstr 3055). We have additionally examined biomarker expression by phenotype in AA pts in our registry to further explain more aggressive behavior in this population. Methods: Stage, grade, ER, PR, Ki-67, HER2, and p53 expressions were compiled for breast carcinomas in 2,230 AA and C pts diagnosed between 1995–2004. Immunohistochemical markers were assayed using antibodies to the above proteins on paraffin-embedded formalin-fixed tissue. Differences in expression were analyzed by Chi- squared and Wilcoxon tests, and survival by Kaplan-Meier estimates. Results: AA pts have higher propensity for basal phenotype breast cancers (20.8% vs 10.4%, p<0.001) and lower propensity for Luminal A/B (ER+/PR+-/HER2-) phenotype (44.2% vs. 54.1%, p<0.001) as compared with C pts. Higher ki-67 proliferation index was found in AA pts (86.4% vs 78.8% in basal, p=0.3423; 37.1% vs. 26.7% in Luminal A/B p=0.0233) as compared with C pts. p53-positivity was higher in AA and C pts in all cases (p=0.0158), higher in AA pts with basal phenotype (p=0.2597), but identical in AA and C pts with luminal phenotypes (p=0.881). Survival was similar in basal phenotypes between races in all cases stage for stage, and controlled for ki-67 and p53 status, with a trend toward poorer survival among luminal phenotypes between races. Conclusions: AA pts have higher propensity for basal phenotype breast cancers than C pts, with higher ki-67 expression in both basal and luminal phenotypes, and higher p53 expression in basal phenotype, but these do not correlate with significant differences in survival by phenotype between races. As neither ki-67 index nor p53 expression can therefore solely explain differences in survival rates seen between races, molecular array studies between races and matched by phenotype are proposed.

[Table: see text]

Enhancement of seed vigour following insecticide and phenolic elicitor treatment

Thiamethoxam (CGA 293'343) is a novel broad-spectrum neonicotinoid insecticide. It is commercially used as a seed treatment under the trademark Cruiser (CRZ). Although many reports detail its insecticidal, plant-protecting properties, there are minimal reports concerning the effect on seed germination activities which can be key control points of seedling vigour. In this report, we investigated the effect of CRZ, fish protein hydrolysates (FPH; a known elicitor of pentose-phosphate pathway) and the combination of CRZ and FPH (CF) on seed vigour of pea, soybean and corn. Seed vigour was investigated by estimating germination percentage, shoot height, shoot weight, total soluble phenolic content, antioxidant content, G6PDH (glucose-6-phosphate dehydrogenase) activity, and GPX (guaiacol peroxidase) activity. Addition of FPH to CRZ (CF) seemed to have a slightly positive effect on seed vigour, especially, CF and FPH treatment for corn and FPH treatment for pea, suggesting that pre-sowing treatments may cause positive/negative effects on seed vigour, depending on the concentration of treatments. Further research will be needed to determine their effects and the optimal concentration for seed priming.

365 THE EFFECT OF ADMINISTERING PROGESTERONE AND ESTRADIOL PRIOR TO eFSH ON THE SUPEROVULATORY RESPONSE OF MARES

eFSH has been used to induce multiple ovulation in cycling mares. However, the response to eFSH is variable. Generally, eFSH is initiated 5 to 7 days after ovulation at a time when the follicular population on the ovaries may be variable. The objective of this study was to determine whether administration of progesterone and estradiol for 10 days prior to eFSH (Bioniche Animal Health, Athens, GA) would enhance the response to eFSH administration. Thirty normal cycling mares were assigned to 1 of 2 groups. Group 1: Control eFSH treatment - mares were examined daily with ultrasonography beginning 5 days after ovulation. Once the follicles in these mares reached 20 to 25 mm in size, eFSH treatment (12.5 mg, i.m.) was administered twice a day. Cloprostenol (Schering-Plough, Union, NJ, USA) treatment (250 �g) was administered on the second day of eFSH treatment. eFSH treatment continued until the majority of the cohort of follicles reached e35 mm. Treatment was stopped and after approximately 36 h hCG (2500 IU, i.v.; Chorulon; Intervet, Millsboro, MD, USA) was administered. Group 2: Injectable progesterone + estradiol (150 mg of progesterone and 10 mg of estradiol; P+E) treatment was initiated in diestrus (5 to 7 days post-ovulation) for 8 mares and in early estrus for 7 mares in this group. Injectable progesterone was continued for 10 days and Cloprostenol (250 �g) was administered on Day 10. Mares were then examined daily with ultrasonography and, once they had acquired 20- to 25-mm follicles, eFSH treatment was initiated. Twice-daily injections of eFSH (12.5 mg, i.m.) were continued until a majority of the cohort of follicles was e35 mm. hCG was administered approximately 36 h later. All mares were inseminated with 1 billion progressively motile spermatozoa from one of two stallions on the day of hCG administration and on the following day with cooled semen (1 billion progressively motile spermatozoa) from the same stallion. Data were analyzed by t-test and Fisher's Exact Test. The number of days of eFSH treatment was similar for the P+E (2) vs. the control (1) group (4.2 � 2.0 vs. 4.9 � 1.3 days, respectively). However, the number of ovulations induced in response to eFSH was greater for mares in the eFSH control (1) group (5.6 � 2.0) than for those in the P+E (2) group (3.0 � 1.9). Embryo recovery per flush was also greater for eFSH control (1) mares (2.7) vs. P+E (2) mares (1.1). Embryo quality was excellent or good for all embryos in both groups. Seventy-three percent of the mares (11 of 15) in both groups gave at least one embryo at each recovery attempt. However, more mares in the eFSH control (1) group gave two or more embryos (60%) compared to those in the P+E (2) group (20%). In summary, treatment of mares with P+E prior to eFSH treatment resulted in fewer ovulations, fewer embryos recovered, and fewer mares providing e2 embryos. Thus, there was no advantage in pretreating mares with P+E prior to eFSH treatment.

249 EFFECT OF REFREEZING BULL SEMEN ON IVF SUCCESS RATE

Cryopreserved semen from valuable sires may be available in limited quantities in some situations. A large percentage of the spermatozoa in a thawed straw is potentially wasted since a relatively small number of spermatozoa are required for most assisted reproduction techniques. The goal of this study was to determine the effect of dilution and refreezing of bull semen on fertilization and blastocyst development rates following in vitro fertilization. The hypothesis was that frozen bull semen that was thawed, diluted, and refrozen could be used successfully for IVF. Oocytes were harvested from cow ovaries collected from a local abattoir and matured in vitro for 24 hours. Ova were subsequently assigned to one of four in vitro fertilization treatment groups. Group 1 ova (n = 158) were fertilized with bull semen frozen at a concentration of 20 × 106 spermatozoa per 0.25 mL straw. Group 2 ova (n = 157) were fertilized with semen frozen at an initial concentration of 2 × 106 spermatozoa. Group 3 ova (n = 157) were fertilized with semen that had been thawed and refrozen at a concentration of 20 × 106 spermatozoa. Group 4 ova (n = 150) were fertilized with semen that had initially been frozen at a concentration of 20 × 106 spermatozoa and then thawed, diluted to a concentration of 2 × 106 spermatozoa, and refrozen. IVF was performed in a medium volume of 100 μL using 1 × 106 spermatozoa/mL. Cleavage and blastocyst rates were determined 2 days and 7 days, respectively after IVF. Cleavage rates following IVF was highest with semen frozen at 20 × 106 spermatozoa (89.9%), intermediate with semen frozen at 2 × 106 spermatozoa or refrozen at 20 × 106 spermatozoa (71.3% and 73.9%, respectively), and lowest with semen refrozen at 2 × 106 spermatozoa (38.7%) (P < 0.05). Blastocyst development rate was not significantly different (P > 0.05) among treatment groups. This study confirmed the hypothesis that refrozen bovine semen can be used successfully for in vitro fertilization. Although the overall IVF efficiency was lower using diluted refrozen semen, multiple IVF procedures could theoretically be performed over time from one initial straw. Consequently, if a limited amount of frozen semen is available, thawing of a single straw followed by dilution, re-allocation into multiple straws, and refreezing should be considered to facilitate the more efficient use of semen in future assisted reproduction endeavors. This study was supported by the PEG Program, Colorado State University.

Individualised quality of life after pacing. Does mode matter?

AIMS

To examine the hypothesis that atrial based pacing improves Quality of Life (QoL) after pacing by undertaking a detailed QoL evaluation that includes an individualised assessment as well as disease specific evaluation.

METHODS

Prospective study of patients randomised to VVI(R) or atrial based pacing modes using the Schedule for the Evaluation of Individual QoL (SEIQoL), the 36-item Medical Outcomes Study Short-Form General Health Survey (SF36), and a modified version of the Karolinska Cardiovascular Symptomatology Questionnaire (KCSQ).

RESULTS

Seventy-three patients completed the two-year follow up of the study. Pacing improved SEIQoL scores, cardiovascular symptoms and the physical role limitation, social limitation and mental health domains of SF36 from baseline to one month. Pacing mode had no effect on QoL the major determinants of which were baseline QoL and a history of coronary artery disease.

CONCLUSION

Atrial based pacing does not improve QoL in the two years after pacing when compared with VVI(R) pacing.

Validation of a telephone cognitive assessment test battery for use in chronic fatigue syndrome

We compared a computerized version of the Cognitive Drug Research (CDR) cognitive assessment test battery and a completely automated telephone version of the same battery. These assessed aspects of attention, working memory and long-term memory. Both methods were used to assess the cognitive performance of a cohort of 30 people with confirmed chronic fatigue syndrome (CFS) and a group of 30 healthy controls matched for age and education. The CFS group had significantly slower reaction times on all four cognitive measures on both the computerized and telephone tests. The mood data followed similar patterns inthe computer and telephone assessments. The results from both forms of the test battery confirmed the pattern and severity of cognitive impairment in CFS. Furthermore, the two methods of testing were similarly sensitive in detecting cognitive deficits. The incapacitating nature of CFS may cause problems for researchers if the restrictions to mobility affect the representativeness of the study group. The findings of the present study support the use of a fully automated telephone cognitive testing system for detecting deficits in CFS.

Prenatal diagnosis of congenital nephrosis by in utero kidney biopsy

The diagnosis of congenital nephrosis is difficult during the antepartum period. The combination of an elevated amniotic fluid alpha-fetoprotein, a negative acetylcholinesterase, and a negative ultrasound examination is highly indicative of congenital nephrosis; however, these findings can also be associated with a normal gestation. This is the first report of pathologic confirmation of congenital nephrosis from an in utero fetal kidney biopsy.

Laser resurfacing of silicone-injected skin: the "silicone flash" revisited

OBJECTIVE

To determine whether prior silicone injection increases the risks associated with carbon dioxide laser resurfacing.

DESIGN

Laboratory determination of the effect of laser energy on liquid silicone; histologic evaluation of silicone-injected skin after lasing; and histologic demonstration of silicone deposits in all layers of dermis years after injection of silicone as filler fluid.

SETTING

Tertiary care medical center. PATIENT-RELATED DATA: Histologic examination of freshly excised skin injected with microdroplets of liquid silicone and subjected to application of carbon dioxide laser energy; histologic examination of skin excised years after silicone injection.

INTERVENTIONS

High-speed clinical photographic imaging of the effect of laser energy on silicone fluid; histologic examination of hematoxylin-eosin-stained sections of skin injected with liquid silicone and subsequently lased.

MAIN OUTCOME MEASURES

Response of liquid silicone to application of laser energy; effect of this response on surrounding normal skin.

RESULTS

Exposure of microdroplets of liquid silicone to carbon dioxide laser energy produced flaring with frank flame. Flaring of dermal silicone caused collateral skin damage.

CONCLUSIONS

Prior injection with liquid silicone is a relative contraindication to cutaneous resurfacing with the carbon dioxide laser. Surgical excision of silicone-injected skin may be preferable for many patients. A strenuous needs assessment should be done, alternatives for skin rejuvenation considered, and comprehensive informed consent obtained from the patient before embarking on laser resurfacing of silicone-injected skin.

Diabetic nephropathy

Diabetic nephropathy is the leading cause of end-stage renal disease in the United States and the largest contributor to the total cost of diabetic care. In addition to the development of diabetic nephropathy and end-stage renal failure, diabetic patients with evidence of albuminuria have a much higher risk of developing myocardial infarctions, cerebrovascular accidents, severe progressive retinopathy, and neuropathy. This article characterizes the clinical and pathologic features of diabetic nephropathy and reviews the major pathogenetic theories that underlie the development of this dreaded complication of diabetes. Widespread screening for this condition and aggressive treatment of diabetic nephropathy at early stages of disease are critical to diminish the risk of costly late complications.

Effect of anti-transforming growth factor-beta antibodies in cyclosporine-induced renal dysfunction

BACKGROUND

Several experimental and clinical studies have implicated a role for transforming growth factor-beta (TGF-beta) in mediating the nephrotoxic effects of cyclosporine (CsA). To test this hypothesis, we administered neutralizing anti-TGF-beta antibodies (alpha-TGF-beta) in a well-described rat model of chronic CsA nephrotoxicity.

METHODS

We studied three groups (N = 9 per group) of adult, male Sprague-Dawley rats that received a low-salt diet (0.05% sodium). Normal controls were given vehicle subcutaneously and an alternate-day intraperitoneal injection of 3 mg of nonspecific mouse IgG (MIgG) for 28 days. The CsA group received 15 mg/kg/day of CsA subcutaneously and 3 mg of MIgG intraperitoneally on alternate days for 28 days. The CsA/alpha-TGF-beta group received CsA and alternate-day alpha-TGF-beta (3 mg) for 28 days. At the end of 28 days, creatinine clearance was measured by 24-hour urine collection. Histologic assessment was performed for tubulointerstitial damage and arteriolar hyalinosis. Northern analysis was performed for alpha 1(I) collagen and TGF-beta 1 gene expression, and quantitative reverse transcription-polymerase chain reaction was performed to measure levels of tissue inhibitor of metalloproteinase-1 (TIMP-1), TIMP-2, plasminogen activator inhibitor-1 (PAI-1), matrix metalloproteinase-2 (MMP-2), and MMP-9.

RESULTS

CsA-treated rats had significantly lower creatinine clearance as compared with normal controls (0.43 +/- 0.07 vs. 0.67 +/- 0.14 mL/min, P = 0.0002), increased interstitial damage and afferent arteriolar hyalinosis (P = 0.0001), and increased alpha1(I) collagen (4-fold) and TGF-beta 1 (2.5-fold) mRNA expression. CsA-treated rats also had significantly increased TIMP-1 (7.4-fold, P < 0.001), MMP-2, and PAI-1 (all approximately 2-fold, P < 0.02) and decreased MMP-9 (85% reduction, P < 0.001) as compared with controls. Treatment with alpha-TGF-beta in CsA-treated rats significantly prevented the reduction in creatinine clearance (0.58 +/- 0.03 mL/min, P = 0.009 vs. CsA alone), the increase in afferent arteriolar hyalinosis (P < 0.05 vs. CsA alone), normalized alpha 1(I) collagen mRNA levels, and attenuated CsA effects on TGF-beta1, TIMP-1, and MMP-9.

CONCLUSIONS

In this rat model of CsA-induced nephrotoxicity, renal insufficiency and characteristic histologic changes are associated with altered expression of matrix and matrix-regulating molecules. Based on our results with alpha-TGF-beta antibodies, many but not all of these nephrotoxic effects of CsA are mediated by TGF-beta.

Effects of pre- and postnatal cysteamine exposure on renal function in the rat

The safety of cysteamine after renal transplantation and during pregnancy is an important issue, since girls with cystinosis are in better health on cysteamine therapy and thus more likely to become pregnant. In the first study, cysteamine was given to pregnant rats on days 6.5-18.5 post conception in oral doses of 0, 37.5, 75, 100, and 150 mg/kg per day. The dams were sacrificed on day 20.5, the fetal kidneys removed and prepared for histological examination. In the second study, cysteamine was given to dams on days 6.5-19.5 post conception in oral doses of 0, 37.5, 50, and 75 mg/kg per day. Dams were allowed to give birth naturally and pups were given cysteamine on days 4-21 to yield the same oral doses of cysteamine given to the dam. Renal function was evaluated on day 35. Histological examination of fetal kidneys revealed no changes even in kidneys from fetuses with growth retardation and malformations. Furthermore, there were no alterations in renal function in offspring on day 35. These findings demonstrate that cysteamine therapy does not affect renal development in the rat. Further investigations will be required to prove whether cysteamine therapy has the potential to affect renal development in the human.

Effect of intravesical capsaicin and vehicle on bladder integrity control and spinal cord injured rats

PURPOSE

To determine the acute effect of intravesical capsaicin on bladder mucosal integrity in normal and spinal cord injured (SCI) rats.

MATERIALS AND METHODS

Intravesical reagents were instilled in 5 groups of age and weight matched female rats: 1) control + normal saline solution (NSS), 2) control + ethanol (EtOH), 3) control + capsaicin/EtOH, 4) SCI + NSS, 5) SCI + capsaicin/EtOH. Intravesical instillations were performed 4 weeks after a standard T10 SCI. Intravesical capsaicin (1 mM.) was dissolved in 30% EtOH/NSS. The animals (n = 3 each group) were sacrificed at 30 minutes, 24 hours, 72 hours, and 7 days after intravesical instillation. Whole bladders were harvested, fixed in 10% buffered formalin, and paraffin embedded. Tissue blocks were blind coded and sectioned (5 microns thickness) for histopathological analysis. All sections were initially stained with hematoxylin and eosin (H & E). Specific staining for mucin carbohydrate moieties included periodic acid-Schiff (PAS) and alcian blue. Also, immunohistochemical staining for GP51 (a urinary glycoprotein) was performed.

RESULTS

Control and SCI rats exhibited similar bladder mucosal histology by H & E and mucin specific stains. Instillation of saline demonstrated no effect on bladder histology, whereas instillation of intravesical capsaicin induced a profound acute effect of thinning of the epithelium, submucosal edema, and diminished presence of GP51. EtOH produced similar pathological findings, but to a lesser degree than capsaicin. Intravesical capsaicin demonstrated a similar effect in both control and SCI animals. The peak effect was seen after 30 minutes and continued for 24 hours. Partial recovery was noted after 72 hours and complete recovery was evident by 1 week.

CONCLUSIONS

The control and SCI rats demonstrated a histologically similar mucosa and glycosaminoglycan layer. The effect of saline instillation on the mucosa was negligible. Intravesical capsaicin dissolved in 30% ethanol/NSS had a profound effect on the bladder urothelium submucosa that was more pronounced than that seen with the ethanol vehicle alone in normal animals.

Replacement of Fhit in cancer cells suppresses tumorigenicity

The candidate tumor suppressor gene, FHIT, encompasses the common human chromosomal fragile site at 3p14.2, the hereditary renal cancer translocation breakpoint, and cancer cell homozygous deletions. Fhit hydrolyzes dinucleotide 5',5"'-P1,P3-triphosphate in vitro and mutation of a central histidine abolishes hydrolase activity. To study Fhit function, wild-type and mutant FHIT genes were transfected into cancer cell lines that lacked endogenous Fhit. No consistent effect of exogenous Fhit on growth in culture was observed, but Fhit and hydrolase "dead" Fhit mutant proteins suppressed tumorigenicity in nude mice, indicating that 5',5"'-P1, P3-triphosphate hydrolysis is not required for tumor suppression.

Comparative analysis of smooth muscle isoactin gene expression in normal and neoplastic tissues

Monoclonal antibodies derived from the actin multigene family are routinely used as an adjunct to morphologic diagnoses of smooth muscle tumors. Northern blot analysis was performed on 60 surgical resections utilizing isoactin-specific cDNAs. A comparison of this analysis to immunohistochemical studies demonstrated that actin-specific monoclonal antibodies represent reliable markers of the smooth muscle lineage. Smooth muscle neoplasms showed a unique pattern of gamma-smooth muscle isoactin gene expression, providing a potentially valuable molecular adjunct to the morphologic diagnosis of uterine smooth muscle tumors.

Molecular determination of the malignant potential of smooth muscle neoplasms

BACKGROUND

The determination of the malignant potential of smooth muscle neoplasms remains ambiguous, and yet has far reaching clinical, therapeutic, and social implications.

METHODS

In this pilot study, the authors examined smooth muscle isoactin gene expression by polymerase chain reaction in a variety of smooth muscle tumors.

RESULTS

A lack of gamma-smooth muscle isoactin gene expression correlated 100% with a pathologic diagnosis of sarcoma. These results suggest that gamma-smooth muscle isoactin gene expression represents a unique molecular marker of oncogenic transformation.

CONCLUSIONS

gamma-Smooth muscle isoactin gene expression provides a valuable molecular adjunct to the diagnosis of smooth muscle neoplasms.

Molecular marker for development of interstitial cystitis in rat model: isoactin gene expression

PURPOSE

To determine whether the differential expression of bladder smooth muscle isoactin can be used as a molecular marker for the development of interstitial cystitis (IC).

METHODS

Three groups of five female Sprague-Dawley rats each underwent urethral catheterization and intravesical instillation of 0.5 ml. of 0.4N HCl. One group was sacrificed one, two and four weeks after the application of HCl, and their bladders harvested for histologic examination and evaluation using Northern blot analysis of bladder smooth muscle isoactins. Five control animals were sacrificed and their bladders harvested to establish isoactin gene expression of bladder smooth muscle in the normal state. The bladders of the rats in each group were excised, immediately frozen in liquid nitrogen, pooled, then stored -70 degrees C until needed for RNA isolation. Isoactin cDNA probes have been developed, therefore isoactin specific cDNA insert fragments were isolated and insert DNA was purified by gel electrophoresis. Total cellular RNA was isolated from 1.0 gm. of bladder smooth muscle from each group. After spectrophotometric quantification, Northern Blot analysis was performed using 2% agarose-formaldehyde gels and Biotrans nylon membranes. Two complete Northern Blot series were run on a single gel and blotted to a single membrane to eliminate gel and blotting discrepancies.

RESULTS

Microscopic histologic analysis revealed detrusor mastocystosis and eosinophilia as has been noted in humans with chronic interstitial cystitis. Two weeks after the intravesical application of hydrochloric acid, the relative expression of gamma-smooth muscle isoactin was noted to increase by 1.7-fold, while alpha-smooth muscle isoactin expression increased by a factor of 9. These effects were seen to stabilize four weeks after acid application.

CONCLUSIONS

The intravesical application of dilute HCl in rats results in a histologic appearance which mimics that seen in humans with interstitial cystitis. The appearance of detrusor mastocytosis and eosinophilia was accompanied by a relative decrease in the expression of gamma- and a relative increase in alpha-smooth muscle isoactin gene expression. This pattern of smooth muscle isoactin expression is consistent with a more immature and possibly synthetic smooth muscle phenotype, which may be responsible for the clinical presentation of those with IC. Northern blot analysis of bladder smooth muscle cells may serve as an effective marker for the development of interstitial cystitis in humans.

Structure and expression of the human FHIT gene in normal and tumor cells

The FHIT gene, encoded by 10 exons in a 1.1-kb transcript, encompasses approximately 1 Mb of genomic DNA, which includes the hereditary RCC t(3;8) translocation break at 3p14.2, the FRA3B common fragile region, and homozygous deletions in various cancer-derived cell lines. Because some of these genetic landmarks (e.g., the t(3;8) break between untranslated FHIT exons 3 and 4, a major fragile region that includes a viral integration site between exons 4 and 5, and cancer cell homozygous deletions in intron 5) do not necessarily affect coding exons and yet apparently affect expression of the gene product, we examined the FHIT locus and its expression in detail in more than 10 tumor-derived cell lines to clarify mechanisms underlying aberrant expression. We observed some cell lines with apparently continuous large homozygous deletions, which included one or more coding exons; cell lines with discontinuous deletions, some of which included or excluded coding exons; and cell lines that exhibited heterozygous and/or homozygous deletions, by Southern blot analysis for the presence of specific exons. Most of the cell lines that exhibited genomic alterations showed alteration of FHIT transcripts and absence or diminution of Fhit protein.

BMP7 null mutation in mice: developmental defects in skeleton, kidney, and eye

While generating bcl2 alpha transgenic mice, we found some F2 offspring of one of the transgenic lines which were very small and had closed eyes at the time of weaning. These pups died within 1 month after birth. In order to determine the molecular basis of this phenotype, we screened a genomic library of the above transgenic line with a transgene-specific probe and found that the Bmp7 gene, a member of the TGF beta superfamily, was inactivated by insertional mutagenesis due to transgene integration. The Bmp7 homozygous null condition in mice is a postnatal lethal mutation and is associated with various developmental defects: holes in the basisphenoid bone and the xyphoid cartilage, retarded ossification of bones, fused ribs and vertebrae, underdeveloped neural arches of the lumbar and sacral vertebrae, polydactyly of the hind limbs, a kinked tail, a reduced number of nephrons, polycystic kidney, lack of retinal pigmentation, and retarded lens development. These findings indicate that BMP7 is an important signaling molecule for normal development of the mammalian skeleton, kidney, and eye. Academic Press

Tumefactive cartilage proliferation after rhinoplasty. A newly reported complication

OBJECTIVE

To describe and document the development of tumoral proliferation of cartilage in 4 patients after nasal surgery, a complication that, to our knowledge, has not been reported before.

DESIGN

Similar postoperative nasal masses were excised from 4 patients who underwent rhinoplasty. Histopathologic evaluation was carried out to identify the nature of the lesions and to provide a basis for rational management of similar lesions subsequently encountered.

SETTING

Academic tertiary referral center.

PARTICIPANTS

Four healthy patients (3 women and 1 man) ranging in age from 21 to 49 years. Two of the patients underwent routine rhinoplasty with resection of cephalic margins of alar cartilages, and 2 underwent augmentation procedures with implantation of auricular cartilage.

INTERVENTION

Discrete firm masses were excised from each patient's nose approximately 1 year after the most recent rhinoplastic procedure was performed. Histological evaluation was carried out on each specimen.

RESULTS

All 4 masses were found to consist of tumefactive proliferation of cartilage. Clonal proliferation and mild nuclear atypia were observed.

CONCLUSIONS

After rhinoplasty, progressive asymmetrical fullness in or adjacent to cartilaginous structures or graft material should suggest the possibility of tumefactive proliferation of cartilage and should be evaluated with surgical exploration. All areas of thickened cartilage should be excised completely, with immediate auricular cartilage reconstruction of resulting anatomical defects. Perichondrium should be completely removed from auricular cartilage implants in the nose, and mechanical injury to the graft should be minimized. We strongly caution against morsellizing dorsal cartilage implants for nasal reconstruction.

Interleukin 10 production by human melanoma

Interleukin 10 (IL-10) has the physiological role of down-regulating cell-mediated immunity. We have recently reported that mRNA for IL-10 was present in most metastatic melanoma tissues. The purpose of this investigation was to determine whether melanoma metastases produce IL-10 protein. Single-cell suspensions were prepared by enzymatic dissociation of 28 lymph node metastases and 7 s.c. metastases and cryopreserved. Of these 35 samples, 30 produced IL-10 after a 24-h incubation (median, 125.1 pg/ml). IL-10 production was slightly diminished after 25 Gy irradiation but almost completely abrogated after modification with the hapten dinitrophenyl. After 7 or 14 days in tissue culture, melanoma cells continued to produce IL-10 but only at about 10% of the levels of freshly dissociated tissues. Moreover, of eight melanoma cell lines established from these cultures, only one produced IL-10 protein. To determine whether IL-10 was produced by melanoma cells or tumor-associated leukocytes, single-cell suspensions were fractionated with anti-CD45 antibody-conjugated magnetic beads. In four of five samples, IL-10 production was increased by depletion of leukocytes, suggesting that the primary source was the melanoma cells themselves. This was confirmed by immunohistochemical staining of cytospin preparations and frozen tissue sections. Finally, 10 of 55 patients with clinically evident metastases showed elevations of circulating IL-10; three patients who had been melanoma-free developed high serum IL-10 levels, concurrent with the appearance of distant metastases. These data indicate that production of IL-10 is characteristic of metastatic melanomas and raise the possibility that this cytokine allows tumors to avoid or to modulate immunological attack.

The FHIT gene, spanning the chromosome 3p14.2 fragile site and renal carcinoma-associated t(3;8) breakpoint, is abnormal in digestive tract cancers

A 200-300 kb region of chromosome 3p14.2, including the fragile site locus FRA3B, is homozygously deleted in multiple tumor-derived cell lines. Exon amplification from cosmids covering this deleted region allowed identification of the human FHIT gene, a member of ther histidine triad gene family, which encodes a protein with 69% similarity to an S. pombe enzyme, diadenosine 5', 5''' P1, P4-tetraphosphate asymmetrical hydrolase. The FHIT locus is composed of ten exons distributed over at least 500 kb, with three 5' untranslated exons centromeric to the renal carcinoma-associated 3p14.2 breakpoint, the remaining exons telomeric to this translocation breakpoint, and exon 5 within the homozygously deleted fragile region. Aberrant transcripts of the FHIT locus were found in approximately 50% of esophageal, stomach, and colon carcinomas.

Loss of heterozygosity at the familial RCC t(3;8) locus in most clear cell renal carcinomas

Previously, we had observed that more than 80% of clear cell renal carcinomas (RCCs) exhibited loss of heterozygosity (LOH) between the microsatellite markers D3S1285 (in 3p14.1) and D3S1295 (in 3p21.1), a region which includes the protein tyrosine phosphatase gamma locus (PTPRG locus, PTP gamma gene) and the 3p14.2 break of the familial RCC-associated translocation, t(3;8)(p14.2;q24), which has been hypothesized to affect expression of an RCC suppressor gene or oncogene. Using seven microsatellite markers and four markers derived from a PTPRG YAC contig, we have further delineated the 3p14.2 region of LOH in RCCs. Eighty-nine % of clear cell RCCs (31 of 35) showed a common region of loss between the D3S1481 and D3S1312 loci which flank the 3p14.2 t(3;8) translocation breakpoint and the PTP gamma gene. The PTP gamma gene occupies approximately 780 kilobase pairs between markers D3S1480 and D3S1312, with its currently defined 5' end greater than 200 kilobase pairs centromeric to the 3p14.2 translocation break. Although most of the RCCs with LOH between D3S1481 and D3S1312 loci have lost at least a portion of one PTP gamma allele, we have tested all known exons of the remaining PTP gamma gene in a number of the kidney tumors and have not observed mutations. Thus, there may be another gene in the vicinity of the 3p14.2 break that is important not only in the familial RCCs in the t(3;8) family but in the majority of clear cell RCCs.

Isolated Castleman disease of the neck: MR findings

Castleman disease in an 11-year-old girl appeared as a neck mass that grew despite antibiotic treatment. MR showed a well-defined solid mass, isointense with muscle on short-repetition-time/short-echo-time images, with a stellate area of central hypointensity on long-repetition-time/long-echo-time images, that did not enhance with gadolinium.

Evaluation of the atypical cytologic smear. Validity of the 1991 Bethesda System

The 1991 Bethesda System states that atypical squamous or glandular cells of undetermined significance should be further classified as reactive or premalignant/malignant. The validity of this qualification for identification of patients with cervical intraepithelial neoplasia (CIN) was tested. One hundred twenty-four cytologic smears with squamous atypia were reviewed retrospectively by two cytopathologists blind to the colposcopy results. The smears were classified as favoring either reactive or premalignant/malignant processes. Subjective criteria used in the classification were based on the pathologists' experience. All patients underwent colposcopy and selected biopsy under the direction of a gynecologic oncologist. Of the 124 atypical smears, 69 were classified as favoring reactive processes and 55 as favoring premalignant/malignant processes by cytopathologist 1. Cytopathologist 2 classified 68 as reactive and 56 as premalignant/malignant. Colposcopy and selected biopsy revealed the following lesions: 34 cases of human papillomavirus (27.4%), 17 of CIN 1 (13.7%), 4 of CIN 2 (3.2%), 2 of CIN 3 (1.6%) and 67 without pathology (54.0%). All six patients with squamous atypia and underlying CIN 2 and 3 lesions had their cytology classified as premalignant/malignant by the cytopathologists. In these patients this qualification had high sensitivity (100%) and negative predictive value (100%). The 1991 Bethesda System classification above, when applied to patients with squamous atypia, was effective in identifying patients with serious pathologic cervical lesions. If used as a triage method, colposcopy should be reserved for atypical lesions classified as premalignant/malignant, potentially decreasing the cost of health care without decreasing the quality of that care.

Common regions of deletion in chromosome regions 3p12 and 3p14.2 in primary clear cell renal carcinomas

Nearly all clear cell renal cell carcinomas (RCCs) exhibit loss of alleles on the short arm of chromosome 3. Loss and mutation at the von Hippel-Lindau (VHL) gene at 3p25 probably occurs in most RCCs and, since the VHL gene was recently cloned, data on VHL involvement in RCCs is accumulating. However, the region 3p14-p12, a region that contains the familial RCC-associated t(3;8)(p14.2;q24) chromosome translocation and the small cell lung carcinoma-associated homozygous deletion at 3p13-12, has also been reported to exhibit allele loss in a large fraction of RCCs. In order to focus future studies on potential suppressor genes in the 3p14-p12 region, we have studied allele loss in 30 RCCs with 9 polymorphic simple sequence repeat markers spanning 3p21.1-p12. Partial losses in the 3p21-p12 region were observed, allowing determination of common regions of loss of heterozygosity overlap in 15 RCCs. Results suggested that most RCCs exhibit loss in a region which brackets the t(3;8) familial chromosome translocation at 3p14.2, and some show additional deletions within the U2020 small cell lung carcinoma deletion at 3p12.

Laparoscopic interstitial contact laser ablation of renal lesions: an experimental model

Tissue ablation with the interstitial Nd:YAG contact laser is a rapidly evolving technique. The urologic applications of interstitial lasers have not been fully investigated. We developed a model to test the feasibility of using interstitial laser energy, administered under laparoscopic guidance, to ablate porcine renal tissue. Utilizing a synthetic sapphire interstitial Nd:YAG contact probe, minimal tissue effects were observed using total energies between 120 and 240 J. At energies of 480 J (8 W/60 seconds), there was predominantly coagulation necrosis of the renal parenchyma. At 720 J (12 W/60 seconds), there was pronounced tissue vaporization surrounded by a zone of coagulation necrosis approximately 1.5 cm across. This preliminary investigation demonstrates that the interstitial Nd:YAG contact laser probe can be used for both controlled coagulation necrosis and vaporization of renal parenchymal tissue. This approach may be applicable to the laparoscopic ablation of small renal lesions in selected patients.

Urinary tract glycoprotein: distribution and antigenic specificity

It has previously been demonstrated that the urinary tract contains a unique glycoprotein (GP1) that appears to serve a function in the clearance of pathogenic bacteria. We prepared a panel of monoclonal antibodies (mAbs) to human GP1 and examined its antigenic specificity and distribution in the human urinary tract. This was also observed in relation to another glycoprotein associated with infection, Tamm-Horsfall protein (THP), as well as to URO-5, a protein used in identifying the lower urinary tract. In enzyme-linked immunoadsorbent assays (ELISA), all of the GP1 mAbs reacted with GP1 prepared from both human urine and rabbit bladder mucosa. No immunoreactivity was observed with either THP mAbs or URO-5 mAbs. Western-blot analyses using GP1 mAbs with human urine GP1 preparations detected a single band of approximately 50-52 kDa. Human urinary tract tissues were also examined by immunohistochemical techniques using the GP1 mAbs, commercial THP, and URO-5 mAbs. In paraffin-embedded bladder sections, only GP1 mAbs reacted with the urothelium. Selective staining of distal collecting tubules, renal pelvis, and ureters was demonstrated for GP1 mAbs. Proximal convoluted tubules, loops of Henle, and Bowman's capsule failed to stain for GP1. In the same tissues, THP mAbs reacted with the thick and thin segments of medullary loops of nephrons (Henle's loops). URO-5 mAbs stained fresh frozen sections of bladder urothelium, distal collecting tubules, and portions of Henle's loops; however, they failed to stain paraffin-embedded tissue sections. These GP1 mAbs provide a new tool for biochemical and histochemical investigations of the mucin layer in both healthy and diseased urinary tract tissue.

Simplified and objective assessment of spermatogenesis in spinal cord injured men by flow cytometry analysis

Deterioration of the germinal epithelium of the testis is a known sequela of spinal cord injury (SCI) that may influence the outcome of male reproductive rehabilitation efforts. Quantitative testicular biopsy, currently regarded as the standard of assessing the integrity of spermatogenesis, has not gained wide-spread clinical use because of its invasive nature and relative technical complexity. Alternatively, aspiration DNA flow cytometry analysis of the testis has offered a potential method of spermatogenic assessment that meets both the requirements of simplicity and objectivity. The objective of this study is to determine the capability of flow cytometry to assess spermatogenesis following SCI. Eleven SCI men underwent incisional testicular biopsy with the specimen simultaneously submitted for quantitative evaluation of the germinal epithelium by both quantitative histometry and DNA flow cytometry. The haploid percentage of cells showed highly significant levels of correlation with key micrometric parameters of the quantitative testicular biopsy: spermatid/tubule (p < 0.002) and the spermatid/Sertoli cell ratio (p < 0.0005). Since tissue procurement is accomplished less invasively for flow cytometry analysis, we recommend this method as the modality of assuring integrity of the germinal epithelium in candidates for reproductive rehabilitation.

Intravesical growth of murine bladder tumors assessed by transrectal ultrasound

Experimental studies in the therapy of intravesically growing bladder tumors in mice have been hampered by an inability to monitor tumor growth before and during treatment. To establish a repeatable, noninvasive method to monitor the intravesical growth of bladder tumors, MB49 murine bladder tumor cells were instilled into the bladders of syngeneic C57BL/6 mice. Following 3 weeks of growth, the bladders of tumor-bearing and control mice were imaged using a 20 mHz, 6.2 F catheter-based ultrasound transducer inserted rectally. Bladders of tumor implanted and control mice were identified by high resolution endoluminal ultrasound after distension with 0.15 ml. of normal saline. When compared with the results of histologic analysis, transrectal ultrasound (TRUS) accurately identified tumor presence, size, and location.