Impact of Malnutrition on Physical, Cognitive Function and Mortality among Older Men Living in Veteran Homes by Minimum Data Set: A Prospective Cohort Study in Taiwan.

OBJECTIVES: To evaluate the prevalence of malnutrition and its impact on mortality, functional decline and cognitive impairment among elder residents in long-term care settings. DESIGNS: A prospective cohort study. SETTINGS: Two veteran homes in Taiwan. PARTICIPANTS: A total of 1,248 male residents aged equal or more than 65 years. MEASUREMENTS: Charlson's comorbidity index (CCI), Minimum data set (MDS), resident assessment protocols (RAP), Activity of daily living-Hierarchy scale, Cognitive Performance Scale, MDS Social engagement scale. RESULTS: The mean age of participants is 83.1 ± 5.1 years, and the prevalence of malnutrition was 6.1%. Inadequate dietary content (57.9%) and unintentional weight loss (31.6%) account for the majority of malnutrition identified by MDS tool. Higher 18-month mortality rate (25% vs. 14.2%), higher baseline CCI (median 1 vs. 0), and higher baseline sum of RAP triggers (median 8.5 vs. 5) were noted among residents with malnutrition. Furthermore, malnutrition was shown predictive for functional decline (OR: 3.096, 95% CI: 1.715-5.587) and potential cognitive improvement (OR: 2.469, 95% CI: 1.188-5.128) among survivors after adjustment for age, body mass index and CCI. CONCLUSION: Malnutrition among elder men residing in veteran homes was associated with multimorbidities and higher care complexity, and was predictive for mortality and functional decline.

Development of the psychometric property of a Minimum Data-Set-Based Depression Rating Scale for use in long-term care facilities in Taiwan.

OBJECTIVES: Our aim is to develop the psychometric property of the Minimum Data-Set-Based Depression Rating Scale (MDS-DRS) to ensure its use to assess service needs and guide care plans for institutionalized residents. METHODS: 378 residents were recruited from the Haoran Senior Citizen Home in northern Taiwan. The MDS-DRS and GDS-SF were used to identify observable features of depression symptoms in the elderly residents. RESULTS: A total of 378 residents participated in this study. The receiver operating characteristic (ROC) curve indicated that the MDS-DRS has a 43.3% sensitivity and a 90.6% specificity when screening for depression symptoms. The total variance, explained by the two factors 'sadness' and 'distress,' was 58.1% based on the factor analysis. CONCLUSIONS: Reliable assessment tools for nurses are important because they allow the early detection of depression symptoms. The MDS-DRS items perform as well as the GDS-SF items in detecting depression symptoms. Furthermore, the MDS-DRS has the advantage of providing information to staff about care process implementation, which can facilitate the identification of areas that need improvement. Further research is needed to validate the use of the MDS-DRS in long-term care facilities.

Comparative validation of single-shot optical techniques for laparoscopic 3-D surface reconstruction.

Intra-operative imaging techniques for obtaining the shape and morphology of soft-tissue surfaces in vivo are a key enabling technology for advanced surgical systems. Different optical techniques for 3-D surface reconstruction in laparoscopy have been proposed, however, so far no quantitative and comparative validation has been performed. Furthermore, robustness of the methods to clinically important factors like smoke or bleeding has not yet been assessed. To address these issues, we have formed a joint international initiative with the aim of validating different state-of-the-art passive and active reconstruction methods in a comparative manner. In this comprehensive in vitro study, we investigated reconstruction accuracy using different organs with various shape and texture and also tested reconstruction robustness with respect to a number of factors like the pose of the endoscope as well as the amount of blood or smoke present in the scene. The study suggests complementary advantages of the different techniques with respect to accuracy, robustness, point density, hardware complexity and computation time. While reconstruction accuracy under ideal conditions was generally high, robustness is a remaining issue to be addressed. Future work should include sensor fusion and in vivo validation studies in a specific clinical context. To trigger further research in surface reconstruction, stereoscopic data of the study will be made publically available at www.open-CAS.com upon publication of the paper.

A de novo transcriptome assembly of Lucilia sericata (Diptera: Calliphoridae) with predicted alternative splices, single nucleotide polymorphisms and transcript expression estimates.

The blow fly Lucilia sericata (Diptera: Calliphoridae) (Meigen) is a nonmodel organism with no reference genome that is associated with numerous areas of research spanning the ecological, evolutionary, medical, veterinary and forensic sciences. To facilitate scientific discovery in this species, the transcriptome was assembled from more than six billion bases of Illumina and twenty-one million bases of 454 sequence derived from embryonic, larval, pupal, adult and larval salivary gland libraries. The assembly was carried out in a manner that enabled identification of putative single nucleotide polymorphisms (SNPs) and alternative splices, and that provided expression estimates for various life history stages and for salivary tissue. The assembled transcriptome was also used to identify transcribed transposable elements in L. sericata. The results of this study will enable blow fly biologists, dipterists and comparative genomicists to more rapidly develop and test molecular and genetic hypotheses, especially those regarding blow fly development and salivary gland biology.

Expression of parvin-beta is a prognostic factor for patients with urothelial cell carcinoma of the upper urinary tract.

BACKGROUND: Parvin-beta (ParvB), a potential tumour suppressor gene, is a focal adhesion protein. We evaluated the role of ParvB in the upper urinary tract urothelial cell carcinoma (UUT-UC). METHODS: ParvB mRNA and proteins levels in UUT-UC tissue were investigated by quantitative real-time polymerase chain reaction and western blot analysis, respectively. In addition, the expression of ParvB in tissues from patients with UUT-UC at different stages was evaluated by immunohistochemistry. Furthermore, biological functions of ParvB in urothelial cancer cells were investigated using a doxycycline-inducible overexpression system and siRNA. RESULTS: Western blot and mRNA analysis showed downregulation of ParvB expression in frozen UUT-UC tissue. Immunohistochemistry revealed high staining intensity of ParvB in normal urothelium, which decreased markedly at advanced stages of UUT-UC (P=0.0000). Moreover, ParvB was an independent prognostic indicator for disease-specific survival of patients with UUT-UC. Functional assays indicated that overexpression of ParvB in an urothelial cancer cell line resulted in decreased cell growth rate and ability to migrate. In contrast, knockdown of ParvB expression increased cell migration ability. CONCLUSIONS: Downregulation of ParvB expression significantly increased urothelial cancer cell growth and migration. Downexpression of ParvB level in UUT-UC correlated with tumour stage, and was an independent unfavourable prognostic factor for disease-specific survival of patients with UUT-UC.

Urinary cell-free DNA as a potential tumor marker for bladder cancer.

The objective was to assess the possibility of measuring urine creatinine (UCr)-adjusted urinary cell-free (ucf) DNA concentration as a noninvasive screening tool for bladder cancer. Using PicoGreen-based detection, the ucf-DNA/UCr concentration was quantified in urine supernatant specimens from 46 bladder cancer patients and 98 controls and compared to 400-bp real-time PCR-based detection, which detected the amplification of 400-bp beta-actin (named 400-bp ucf-DNA/UCr). The mean concentrations for both PicoGreen and 400-bp ucf-DNA (ng/mL)/UCr (mg/dL) were significantly higher in bladder cancer patients than in controls: 15.28 vs 6.68 (p<0.001, t-test) and 14.98 vs 1.07 (p<0.001), respectively. Among different stages and grades, no significant difference was found between these two methods. The areas under the ROC curves of PicoGreen and 400-bp ucf-DNA/UCr were 0.571 (95% confidence interval, 0.451-0.692) and 0.805 (95% confidence interval, 0.713-0.896), respectively. In 400-bp ucf-DNA/UCr, the best sensitivity and specificity were 86.1% and 72.0% at the cutoff value of 0.0645. These data indicated that 400-bp ucf-DNA/UCr is more reliable for bladder cancer detection than PicoGreen. In conclusion, our results suggest that ucf-DNA/UCr can be used as a potential tumor marker for bladder cancer, especially for detecting longer DNA fragments.

High inguinal loupe-assisted varicocelectomy for subfertile men with varicococeles: technical feasibility, clinical outcomes and complications.

254 consecutive patients underwent high inguinal loupe-assisted varicocelectomy. All patients had at least a one year history of infertility with abnormal semen parameters and physical examination and/or color Doppler ultrasound proven varicocele. To facilitate the procedure, an x 3.0 loupe was used during spermatic cord dissection near or at level of internal inguinal ring. Semen analysis and physical examination were performed at 3 monthly intervals. No intra-operative complications occurred. The most common post-operative complications were transient scrotal pain and stitch reaction, occurring in 12% and 4% of men, respectively. Only one permanent and two transient hydroceles were observed. Recurrent or persistent varicocele was identified by physical examination and color Doppler in 5 varicocelectomies (1.4%), and by color Doppler only in 6 varicocelectomies (1.7%). Sperm motility increased from 30 +/- 8% to 46 +/- 20%, and sperm concentration. (10(6)/cc) increased from 24 +/- 18 to 41 +/- 28. The one-year pregnancy rate was 37%. High inguinal loupe-assisted varicocelectomy is a safe, simple, and effective treatment for varicocele.

Complications following combined transrectal ultrasound-guided prostate needle biopsies and transurethral resection of the prostate.

In order to evaluate safety and morbidity aspects of additional systematic prostate biopsies, we have conducted a retrospective review of patients who had undergone transurethral resection of the prostate (TUR-P) combined with additional systemic prostate needle biopsies at the Chang Gung Memorial Hospital. To this end, the records of 80 men presenting consecutively at our institution between February 2001 and January 2004 inclusively were examined. These 80 individuals included patients experiencing obstructive voiding symptoms and those featuring suspicious screening parameters, all of whom were to undergo transurethral resection of the prostate for symptomatic benign prostatic hyperplasia (BPH), all procedures being performed by a single surgeon. A total of 20 (25%) specimens were found to be positive for prostate cancer. Cancer was detected in the transrectal prostate biopsy specimen of 16 of 57 men (28%) who had not undergone a previous prostate biopsy, and for four of 23 (17%) who had undergone at least one previous (benign) biopsy. Mild complications associated with transurethral prostrate resection, such as hematuria and hemospermia, were reported frequently, featuring rates of 10% and 2.5%, respectively; more severe complications being noted far less frequently. Fever, usually of a low grade, was observed post-operatively for six (7.5%) patients, but a prompt return to normal temperature following antibiotic treatment for one day was revealed. Four (5%) patients remained admitted to the hospital for a prolonged period following surgery. A review of the literature concerning transrectal biopsies and TUR-P has shown that surgery-associated complication rates are slightly lower than was the case for our study. Additional systematic prostate biopsies for patients undergoing TUR-P would appear to be a relatively safe treatment procedure. Identification of risk factors for post-surgery complications might further improve the safety of the screening procedure.

Malignant phyllodes tumor of the prostate.

This is a report of a 70-year-old man with malignant phyllodes tumor of prostate. The retropubic prostatectomy was done. The stroma of the tumor was cellular and composed of elongated cells with spindle shaped nuclei and fragmented bizarre giant cells. After recovery from surgery, prophylatic radiotherapy was given over 2 months. A case report of a patient treated at our medical center and a review of the literature was done.

Loupe-assisted modified one-layer vasovasostomy.

Several studies indicate that microsurgical modified one-layer vasovasostomy is comparable to the two-layer anastomosis with respect to patency and pregnancy rates. The objective of this study was to determine the feasibility and result of modified one-layer vasovasostomy under loupe magnification only. Thirty-two patients aged 28 to 64 years (mean 41.3 +/- 6 years) underwent vasovasostomy at CGMH from July 1997 to June 2002, with all operations being a modified on-layer anastomosis created with the aid of a 3 x loupe. The estimated duration of vasectomy ranged from 4 months to 27 years, with a mean of 9.2 +/- 4.8 years. Postoperative semen analysis and pregnancy were examined. Each patient was followed up at 1,4, and 12 weeks postoperatively. The total operation time ranged from 118 to 228 minutes (average 150 +/- 35 minutes). There was no operation-related complication such as hematoma or wound infection. The patency rate was 89% (25/28), and the pregnancy rate at 2 years or more of follow-up was 39% (11/28). The patency and pregnancy rates were similar to those obtained in most studies of microsurgical vasovasostomy. For uncomplicated vasectomy reversal, this simple loupe-assisted modified one-lyer vasovasostomy seems to provide an adequate anastomosis.

Probability based diagnostic biopsy specimens as predictors of tumor grade and stage found.

The Gleason score of prostatic adenocarcinoma in biopsy specimens was compared with the Gleason score of corresponding radical prostatectomy specimens from 78 patients with localized prostate cancer. Grading errors were found to be significant for well-differentiated (Gleason score 2-4) tumors. The accuracy was 6 (23%) for Gleason scores of 2-4 on needle biopsy. All of the Gleason scores of 8-10 on needle biopsy were graded correctly. When the preoperative Gleason score was <7, 20 (37%) patients had organ-confined lesions, while when preoperative Gleason score > or = 7, 5 (21%) patients were confined to the prostate. Discrepancies between the Gleason score of the biopsy material and prostatectomy specimens were larger for biopsy specimens with low Gleason scores than for biopsy specimens with high Gleason scores. Large differences existed between the Gleason histologic scores of the biopsy and prostatectomy specimens when only a single microscopic focus of the tumor in the biopsy specimen is low grade. Consequently, when tumor grade influences the clinical management of prostate cancer, patients with limited biopsy material, provided this material is not poorly differentiated, should probably undergo repeated biopsy to reduce the likihood of tumor sampling error. This awareness influences treatment policy, particularly for the watchful waiting criteria of prostate cancer.

Minilaparotomy radical retropubic prostatectomy for prostate cancer.

Radical prostatectomy is still the gold standard for treating patients with clinically localized cancer. A total of 33 consecutive patients underwent minilaparotomy radical prostatectomy by a single surgeon. The minilaparotomy radical retropubic prostatectomy was performed via an eight-centimeter lower midline incision and a Book Walter retractor for surgical assistance. Mean patient age was 65 years (range 47 to 74). Tumor stages were observed as 12.1% of total for T1c, 21.2% for T2a, 45.5% for T2b, 6% for T3a and 15.2% for T3b. Satisfactory continence was achieved in 80% of the patients. 85% of patients revealed a prostate-specific antigen at a serum concentration of less than 0.2 ng/ml. Minilaparotomy radical retropubic prostatectomy compares favorably with standard radical retropubic prostatectomy.

Hematuria from left internal pudendal and obturator arterial bleeding following sexual intercourse.

Bladder tamponade is an uncommon clinical symptom among men who experience suffering related to sexual intercourse. The authors report on a 46-year-old man with this symptom 4-5 years before hospitalization. Angiography confirmed the presence of left pudendal and obturator arterial bleeding, and embolotherapy of the internal pudendal and obturator arteries was performed. There was no mortality, or limb loss or loss of sexual potency at follow-up.

Intractable bladder tamponade due to left internal pudendal and obturator arterial bleeding induced by erection: a superselective arteriography followed by transcatheter arterial embolization.

Bladder tamponade is an uncommon clinical symptom among men suffering during sexual intercourse. The authors report on a 46-year-old man for whom this symptom appeared 4-5 years prior to hospitalization. Angiography confirmed the presence of left pudendal and obturator arterial bleeding, and embolotherapy of the internal pudendal and obturator arteries was performed. There was no mortality, or limb loss or sexual potency loss at follow-up.

Deterioration of polyamino acid-coated alginate microcapsules in vivo.

The implantation of immuno-isolated recombinant cell lines secreting a therapeutic protein in alginate microcapsules presents an alternative approach to gene therapy. Its clinical efficacy has recently been demonstrated in treating several genetic diseases in murine models. However, its application to humans will depend on the long-term structural stability of the microcapsules. Based on previous implantations in canines, it appears that survival of alginate-poly-L-lysine-alginate microcapsules in such large animals is short-lived. This article reports on the biological factors that may have contributed to the degradation of these microcapsules after implantation in dogs. Alginate microcapsules coated with poly-L-lysine or poly-L-arginine were implanted in subcutaneous or intraperitoneal sites. The retrieved microcapsules showed a loss of mechanical stability, as measured by resistance to osmotic stress. The polyamino acid coats were rendered fragile and easily lost, particularly when poly-L-lysine was used for coating and the intraperitoneal site was used for implantation. Various plasma proteins were associated with the retrieved microcapsules and identified with western blotting to include Factor XI, Factor XII, prekallikrein, HMWK, fibrinogen, plasminogen, ATIII, transferrin, alpha-1-antitrypsin, fibronectin, IgG, alpha-2-macroglobulin, vitronectin, prothrombin, apolipoprotein A1, and particularly albumin, a major Ca-transporting plasma protein. Complement proteins (C3, Factor B, Factor H, Factor I) and C3 activation fragments were detected. Release of the amino acids from the microcapsule polyamino acid coats was observed after incubation with plasma. indicating the occurrence of proteolytic degradation. Hence, the loss of long-term stability of the polyamino acid-coated alginate microcapsules is associated with activation of the complement system, degradation of the polyamino acid coating, and destabilization of the alginate core matrix, probably through loss of calcium-mediated ionic cross-linking of the guluronic acid polymers in the alginate. These destructive forces may be slightly mitigated by using poly-L-arginine instead of poly-L-lysine for coating and by implanting in a subcutaneous instead of an intraperitoneal site. However, the long-term stability of such devices may require significant improvements in the microcapsule polymer chemistry to withstand such biological impediments.

Development of small alginate microcapsules for recombinant gene product delivery to the rodent brain.

A novel form of gene therapy using encapsulated recombinant cells in alginate microcapsules has proven effective in treating several animal models of human diseases. For treating neurological deficits in rodents with this technology, the size of the microcapsules has to be reduced for implantation in the central nervous system (CNS) to bypass the blood-brain barrier. This article reports the development of small alginate microcapsules suitable for implantation into the mouse CNS. By varying the encapsulation protocol, recombinant cells could be encapsulated in microcapsules ranging in diameter from 5 to 2000 microm. The optimal size for implantation was determined to be 100-200 microm, based on the smallest, homogeneously sized, cell-filled microcapsules that could pass the 500 microm inner diameter of a CNS-implantation needle. Compared with medium-sized (500-700 microm) microcapsules, these small microcapsules packed more tightly together with less inter-capsule space, resulting in an increased number of cells and a higher rate of recombinant gene product secretion per volume of microcapsules. The small microcapsules also displayed increased mechanical strength, compared with large microcapsules. These excellent in vitro properties of small 100-200 microm microcapsules warrant further in vivo investigation into the feasibility of using immuno-isolation gene therapy to deliver recombinant gene products to the rodent CNS.

Improvement of practice performance in urological surgery via clinical pathway implementation.

The purpose of this study was to compare performance measurements to evaluate the effects of clinical pathway implementation on improving practice performances in urology. Since April 1997, a total of 18 clinical pathways have been created in the urology department. Of these clinical pathways, six were implemented for endoscopic surgery, and four and eight were for minor and major surgery, respectively. Eight prominent performance measurements, which were identified as representative indicators of the practice performances, were selected in endoscopic surgery, five in minor surgery, and 11 in major surgery. Between April 1997 and March 1999, 2,883 consecutive patients, who underwent endoscopic surgery, minor surgery, and major surgery, were evaluated herein. The treatment results for patients in the first and second years of clinical pathway implementation were compared to those from the year preceding the implementation. In endoscopic surgery, five of the eight performance measurements improved significantly in the first year of implementation. Notably, three of the five improved performances continued to improve in the second year. Similarly, in minor surgery, four of the five performance measurements improved significantly following 2 years. Finally, in major urological surgery, six of the 11 performance measurements also improved significantly after 1 year; four of which continued to improve during the second year. Therefore, we conclude that patient care, which is based on the implementation of clinical pathways, can improve practice performances and facilitate medical care.

The differences in health outcomes between Web-based and paper-based implementation of a clinical pathway for radical nephrectomy.

OBJECTIVE: To evaluate the effects of a web-based clinical pathway (WCP) for radical nephrectomy on patient care, and to compare the effects with those of a paper-based clinical pathway (PCP). PATIENTS AND METHODS: Patients with renal cell carcinoma and who underwent radical nephrectomy were enrolled into the study. The results of using the WCP for radical nephrectomy from July 2000 to August 2001 were compared with those using the PCP between May 1999 and June 2000. The mean hospital stay, average admission charges, six quality indicators, and the advantages of the WCP were determined. RESULTS: Using a WCP for radical nephrectomy reduced the hospital stay and admission charges by as much as the PCP. A similar number of patients had variances from the WCP as with the PCP (P = 0.407), but the number of undetected variances and the variance detection time in the WCP were significantly less (P = 0.0193 and 0.0162). Implementing a WCP also improved the quality of care by as much as a PCP. CONCLUSIONS: Using a WCP for radical nephrectomy can improve health outcomes by reducing the hospital stay and admission charges, and by improving the quality of care by as much as a PCP. Furthermore, the WCP was more accurate and faster than the PCP in detecting variances.

Treatment of hemophilia B in mice with nonautologous somatic gene therapeutics.

The implantation of nonautologous cells encapsulated in immunoprotective microcapsules provides an alternative nonviral method for gene therapy. This strategy was successful in reversing the disease phenotypes of dwarfism and a lysosomal storage disease, mucopolysaccharidosis VII, in murine models. In this article we implanted transgenic hemophilic B mice with microcapsules enclosing factor IX-secreting C2C12 myoblasts to study the clinical potential of this approach in the treatment of hemophilia. Treated mice showed increased plasma factor IX levels as high as 28 ng of human factor IX per milliliter of plasma and decreased activated thromboplastin times (reduced by 20% to 29%). However, the level of factor IX decreased to baseline levels by day 7, coinciding with emergence of anti-human factor IX antibody, the titer of which increased greater than 10-fold by day 28. Monoclonal anti-CD4 antibodies were used to deplete CD4+ T cells to suppress the immune response against the recombinant factor IX. In the treated hemophilic mice, the anti-factor IX antibody response was totally suppressed to beyond day 28 accompanied by a significant decrease in activated thromboplastin time compared with that seen in untreated hemophilic mice. When the microcapsules were recovered from the intraperitoneal cavity after 38 days of implantation, the encapsulated cells continued to secrete factor IX at preimplantation levels, but both cell viability and microcapsule mechanical stability were reduced. Hence although the polymer chemistry of the microcapsules and cell viability may need to be improved for long-term delivery, nonautologous gene therapy with microencapsulated cells has been shown to be effective, at least for the short-term, in alleviating the hemophilic hemostatic anomaly. Coadministration of an immunosuppressant is effective in inhibiting antibody development against the delivered factor IX and should be considered for recipients at risk of inhibitor development.

Immuno-isolation in oncology--a mini-review.

Immuno-isolation provides a potentially safe and effective method of delivering recombinant therapeutic molecules. Its application as a drug-delivery platform for the treatment of cancer has shown promising developments recently. This review will summarize the principle and current progress of this novel therapy paradigm in oncology. In this approach, a non-autologous cell line is genetically modified to secrete a recombinant product with potential for tumor suppression. Such a cell line may be implanted without graft rejection into all patients with similar neoplastic disease. The immune protection is conferred by enclosure within immuno-isolating devices such as microcapsules whose permeability would allow passage of smaller molecules such as oxygen, nutrients and waste products as well as the desired therapeutic transgene product. However, large immune mediators such as complement, macrophages and lymphocytes responsible for graft rejection would be excluded. In this review, we will consider how this technology may be applied as a novel genetic tool for cancer treatment to deliver antibodies, cytokines, enzymes and growth factors for treatment of various types of cancer. These molecules can be delivered at low constitutive levels, thereby permitting long-term systemic delivery, maintaining biological activity over extended periods, and eliminating the costs of product purification. The current success of this strategy in cancer treatment will be reviewed in in vitro systems, in animal models of cancer, and in human clinical trials.