Prevalence of and factors associated with frailty and disability in older adults from China, Ghana, India, Mexico, Russia and South Africa.

BACKGROUND: The severe burden imposed by frailty and disability in old age is a major challenge for healthcare systems in low- and middle-income countries alike. The current study aimed to provide estimates of the prevalence of frailty and disability in older adult populations and to examine their relationship with socioeconomic factors in six countries. METHODS: Focusing on adults aged 50+ years, a frailty index was constructed as the proportion of deficits in 40 variables, and disability was assessed using the World Health Organization Disability Assessment Schedule (WHODAS 2.0), as part of the Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, Russia and South Africa. RESULTS: This study included a total of 34,123 respondents. China had the lowest percentages of older adults with frailty (13.1%) and with disability (69.6%), whereas India had the highest percentages (55.5% and 93.3%, respectively). Both frailty and disability increased with age for all countries, and were more frequent in women, although the sex gap varied across countries. Lower levels of both frailty and disability were observed at higher levels of education and wealth. Both education and income were protective factors for frailty and disability in China, India and Russia, whereas only income was protective in Mexico, and only education in South Africa. CONCLUSIONS: Age-related frailty and disability are increasing concerns for older adult populations in low- and middle-income countries. The results indicate that lower levels of frailty and disability can be achieved for older people, and the study highlights the need for targeted preventive approaches and support programs.

Tissue stem cells and cancer stem cells: potential implications for gastric cancer.

Gastric cancer remains the second leading cause of death in the world today, making the search for its molecular and cellular basis an important priority. Though recognition of the tight link between inflammation and tumorigenesis is centuries old, only recently are the pieces of the etiological puzzle beginning to fall together. Recent advances in gastric stem cell biology appear to be central to this slowly resolving puzzle. At least two types of stem cells may be important. Resident adult or tissue stem cells may, in a chronically inflamed environment, slowly acquire a series of genetic and epigenetic changes that lead to their emergence as ''cancer stem cells''. This scenario has not yet been proven experimentally, although the first step, prospective recognition of a gastric stem cell has recently been conquered. Alternatively, the setting of chronic inflammatory stress and injury may lead to loss of the indigenous gastric stem cells from their niches; bone marrow derived stem cells may then be recruited to and engraft into the gastric epithelium. Such recruited cells have the potential to contribute to the tumor mass. Indeed, evidence supporting this scenario has been published. Here, we review these recent findings and discuss implications for the future.

Basic science research on the urinary bladder and interstitial cystitis: new genetic approaches.

This article summarizes recent genetic research that promises to advance understanding of the functioning of the urinary bladder and further our knowledge about interstitial cystitis. Results reported at the Tenth International Research Symposium on Interstitial Cystitis and Bladder Research and in the current literature are presented. Three specific areas of genetic research are summarized: gene expression via DNA arrays, development of new animal models through transgenic or gene knockout approaches, and gene therapy. Advances in genetic research (specifically in gene therapy; development of new, genetically engineered mouse models; and study of gene expression using DNA array assays) will contribute to further understanding the functioning of the urinary bladder in health and disease.

Connexin 26 enhances the bystander effect in HSVtk/GCV gene therapy for human bladder cancer by adenovirus/PLL/DNA gene delivery.

Herpes simplex thymidine kinase/ganciclovir (HSVtk/GCV) gene therapy has been used for the treatment of a variety of cancers. Its efficacy is enhanced by the bystander effect that helps overcome the delivery problems commonly observed in current gene therapy. Connexins encode proteins that produce gap junctions, which enable intercellular communication and the bystander effect. We previously demonstrated that decreased Cx 26 expression and loss of gap junctional intercellular communication were associated with human bladder cancer. To investigate the efficacy of the bystander effect in HSVtk/GCV gene therapy, the Cx 26 gene was introduced into UM-UC-3 and UM-UC-14 bladder cancer cell lines by an adenovirus poly-L-lysine conjugate using a multigenic expression plasmid that expressed both the HSVtk and Cx 26 genes. We found significantly increased cytotoxicity in HSVtk/GCV gene therapy after introduction of the HSVtk and Cx 26 genes together compared with the cytotoxicity seen after introduction of the HSVtk gene and LacZ genes in vitro and in vivo. Cytotoxicity correlated with Cx 26 expression and the induction of functional gap junctions. This study indicates that combination gene therapy with co-expression of the HSVtk and Cx 26 genes potentiates HSVtk/GCV gene therapy through the bystander effect.

Identification of effective retinoids for inhibiting growth and inducing apoptosis in bladder cancer cells.

PURPOSE: Retinoids modulate the growth and differentiation of normal and malignant epithelial cells in vitro and in vivo, and inhibit bladder carcinogenesis in animal models. Retinoid analogs have been used in several clinical chemoprevention trials of superficial bladder cancer recurrence. There is a clear need to identify new effective retinoids and develop novel approaches for the chemoprevention and treatment of superficial bladder cancer. We investigated the effects of various retinoids on growth inhibition and apoptosis induction in bladder cancer cell lines. MATERIALS AND METHODS: Ten grades 1 to 3 bladder cancer cell lines and the 4 retinoids all-trans-retinoic acid, 9-cis retinoic acid, 4-(N-hydroxyphenyl) retinamide (4HPR) and LGD1069 were used in the study. We compared the ability of these retinoids to inhibit growth, induce apoptosis, affect the expression of nuclear retinoid receptors and modulate apoptosis related genes. RESULTS: Most bladder cancer cell lines did not express retinoic acid receptor beta and were resistant to the effect of all-trans-retinoic acid and 9-cis retinoic acid on growth inhibition and apoptosis induction, even at a concentration of 10(-5) M. The 2 cell lines that expressed retinoic acid receptor beta were constitutively sensitive to the growth inhibitory effect of all-trans-retinoic acid. 4HPR inhibited cell growth by about 90% in all but 1 cell line and induced apoptosis at a concentration of 10(-5) M after a 24-hour treatment. LGD1069 had virtually no effect. All-trans-retinoic acid and 4HPR induced retinoic acid receptor beta expression in 1 bladder cancer cell line. However, the effect of 4HPR on cell growth and apoptosis were not related to the constitutive expression of retinoic acid receptor beta. 4HPR decreased bcl-2 expression in 6 of 8 bladder cancer cell lines but did not change p53 gene expression. CONCLUSIONS: The results demonstrate that 4HPR is the most potent growth inhibitor and apoptosis inducer of the retinoids tested. Lack of retinoic acid receptor beta expression may be responsible for cell resistance to all-trans-retinoic acid but not to the other retinoids.

Extravesical cryosurgical approach for VX2 bladder tumor in rabbits.

This study characterized the VX2 bladder cancer model in rabbits and tested the feasibility of treating bladder cancer by extravesical cryosurgery. After the growth characteristics of the VX2 bladder tumor model were determined, the VX2 tumor was inoculated into rabbits at the dome of the bladder. One week later, three freeze/thaw cycles were followed by immediate surgical repair. The control group underwent a sham operation without freezing. When the VX2 tumor is injected into the bladder wall, invasion and central necrosis occurred within I week, lymphatic metastases by 2 weeks, and lung metastases by 3 weeks after inoculation. By 4 weeks, all control rabbits had large VX2 tumors in their bladders and advanced lung metastases. Nine of the ten rabbits in the cryosurgical group had mild to moderate degrees of lung metastases, and six of them had relatively small local recurrences. One rabbit had no tumor in the bladder and only microscopic lung metastasis. The extravesical approach to cryosurgery employing bladder inversion is well tolerated. Cryosurgery exhibits modest efficacy in treating local tumors and delaying lung metastasis in this aggressive tumor model.

MMAC1/PTEN inhibits cell growth and induces chemosensitivity to doxorubicin in human bladder cancer cells.

The development and progression of bladder cancer is associated with multiple alterations in the genome, including loss of chromosome 10. Recently, MMAC1/PTEN, a phosphatidylinositol phosphatase, has been mapped to chromosome 10q23. We previously demonstrated that MMAC1/PTEN has tumor suppressive properties in glioblastoma and prostate cancer. To investigate the efficacy of gene therapy with MMAC1/PTEN, we examined whether the exogenous introduction of MMAC1/PTEN via an adenoviral vector (Ad-MMAC) can inhibit tumor growth and reverse drug resistance to doxorubicin in human bladder cancer cells. Human bladder cancer cell lines UM-UC-3 and T24 were infected with Ad-MMAC to induce exogenous expression of MMAC1/PTEN. The cells were then analysed for cell growth and expression of phosphorylated protein kinase B (Akt/PKB) and MMAC1/PTEN. UM-UC-6dox, a doxorubicin resistant subline, was infected with Ad-MMAC to evaluate its role in reversing drug resistance to doxorubicin. We found that MMAC1/PTEN suppressed tumor growth in UM-UC-3 and T24 cells with arrest in the G1 phase of the cell cycle. We also showed that gene therapy with MMAC1/PTEN abrogated phosphorylated Akt/PKB expression in UM-UC-3, T24 and UMUC-6dox cells, and restored doxorubicin sensitivity in UM-UC-6dox. These data demonstrate that MMAC1/PTEN can induce growth suppression and increase sensitivity to doxorubicin in bladder cancer cells and suggest that the MMAC1/PTEN gene and its pathways can be therapeutic targets for bladder cancer.

Inactivation of MMAC1 in bladder transitional-cell carcinoma cell lines and specimens.

We recently limited the location of a candidate tumor suppressor gene in invasive (T3a/b) bladder transitional-cell carcinoma (TCC) to a 2.5-cM region at chromosome 10q23.3. This region harbors the MMAC1/PTEN/TEP1 gene (referred to hereafter as MMAC1), a dual-phosphatase tumor-suppressor gene frequently inactivated in variety of malignant tumors. In the present study, we examined whether MMAC1 is a target for inactivation by mutations and deletions in bladder TCC cell lines and specimens. MMAC1 was inactivated by homozygous deletions and mutations in three (27%) of 11 bladder cancer cell lines. One cell line, UC-3, had homozygous deletions, and two other cell lines, T-24 and UC-9, had missense mutations. T-24 had also a nonsense mutation. However, none of the 33 bladder TCC specimens examined had a mutation or deletion in the coding region. These results suggest that MMAC1 is not the primary target for inactivation in bladder TCC and that another gene, in close proximity to the MMAC1 locus, within this region of frequent allelic losses, may be the target for inactivation.

Characterization of AMC-HN-9, a cell line established from an undifferentiated carcinoma of the parotid gland: expression of alpha6beta4 with the absence of BP180 and 230.

We recently reported the development of a cell line, AMC-HN-9, established from an undifferentiated carcinoma (UDC) of the parotid gland. AMC-HN-9 consists mostly of spindle-shaped cells, has poor in vitro adhesiveness and an in vitro appearance that is different from that of other epithelial cell lines. To test the hypothesis that structural or functional abnormalities of the hemidesmosomes might contribute to the morphological appearance and biology of UDCs, we studied the expression of hemidesmosomal proteins in AMC-HN-9. Flow cytometry, indirect immunofluorescence, immunoprecipitation, reverse transcriptase-polymerase chain reaction, and cytogenetic analysis were used. AMC-HN-9 cells express the alpha6 and beta4 integrin subunits at nearly the same intensity as head and neck squamous cell carcinoma cell lines. However, AMC-HN-9 does not express BP180 and BP230, although there is no gross deletion of the loci of the BP180 and BP230 genes, suggesting that a more subtle mechanism has silenced these genes. In conclusion, the failure to express certain hemidesmosomal proteins is a likely explanation for the functional and morphologic characteristics of UDC cells both in vivo and in vitro.

Expression of the alpha6beta4 integrin provides prognostic information in bladder cancer.

Integrins are cell surface receptors for extracellular matrix components that may participate in metastatic processes. Normal urothelial tissues show a polarized expression of alpha6beta4 integrin on basal cells at their junction with the lamina propria. We have previously shown that bladder cancers frequently overexpress one member of the integrin family, the alpha6beta4 integrin. In this study, we evaluated the level of alpha6beta4 integrin expression in bladder cancer specimens from 57 patients and correlated the expression level with patient survival. Expression was evaluated by immunoperoxidase staining. Three patterns of alpha6beta4 expression were observed: negative (13 patients); strong overexpression throughout the tumor cells (21 patients); and weak expression that most closely resembled expression in normal urothelium (23 patients). Individuals with weak staining tumors had a statistically significantly better survival (p=0.041) than patients whose tumors exhibited either no expression or strong overexpression. These data indicate that evaluation of the expression of alpha6beta4 integrin may provide valuable prognostic information on clinical outcome in patients with bladder cancer.

Combined effect of chemopreventive agent N-(4-hydroxyphenyl) retinamide (4-HPR) and gamma-radiation on bladder cancer cell lines.

The incidence of bladder cancer has increased in the United States during the past 50 years, consistent with increased exposure to bladder carcinogens in the environment and tobacco use. Although N-(4-hydroxyphenyl) retinamide (4-HPR), a retinoid derivative, has been used as a chemopreventive agent of bladder cancer in clinical trials, little is known about its mechanisms of action against bladder cancer cells. Previous studies suggest this chemopreventive agent may inhibit tumor growth by inducing apoptosis. To further investigate this putative effect, we examined the effect of 4-HPR and gamma-radiation and their combined effects in three selected bladder cancer cell lines. Indeed, 4-HPR induced apoptosis in these cell lines in a dose-dependent manner. A 2.5 microM dose of 4-HPR and 50 rad of gamma-irradiation induced about 10% increase in apoptotic cells, respectively. However, this low dose 4-HPR combined with low dose gamma-irradiation had a synergistic effect on apoptosis, in which apoptotic cells increased by more than 30%. The findings have potential clinical implications and warrant further investigations both in vitro and in vivo in bladder cancer.

Relationship among cystectomy, microvessel density and prognosis in stage T1 transitional cell carcinoma of the bladder.

PURPOSE: The selection of therapy for stage T1 bladder cancer is controversial, and reliable biomarkers that identify patients likely to require cystectomy for local disease control have not been established. We evaluated our experience with T1 bladder cancer to determine whether early cystectomy improves prognosis, and whether microvessel density has prognostic value for T1 lesions and could be used for patient selection. MATERIALS AND METHODS: We retrospectively reviewed the records of 88 patients with T1 transitional cell carcinoma of the bladder. Patient outcome was correlated with therapeutic intervention. Paraffin embedded tissue from 54 patients was available for factor VIII immunohistochemical staining for microvessel density quantification. RESULTS: Median followup was 48 months (range 12 to 239). Of the patients 34% had no tumor recurrence. The rates of recurrence only and progression to higher stage disease were 41 and 25%, respectively. The survival of patients in whom disease progressed was diminished (p = 0.0002). Grade did not predict recurrence or progression nor did cystectomy provide a survival advantage. Microvessel density did not correlate with recurrence or progression. CONCLUSIONS: Patients with T1 bladder cancer have a high risk of recurrence and progression. Tumor progression has a significant negative impact on survival. Neither grade nor early tumor recurrence predicted disease progression. Because early cystectomy did not improve patient outcome, we suggest reserving cystectomy for patients with progression or disease refractory to local therapy. Microvessel density is not a prognostic marker for T1 bladder cancer and has no value in selecting patients with T1 disease for cystectomy.

p53 and RB expression predict progression in T1 bladder cancer.

The optimal clinical management of minimally invasive (stage T1) bladder cancer is controversial. T1 bladder cancers share characteristics of both noninvasive (Ta) papillary cancer and high stage, muscle-invasive bladder cancers. Patients with T1 bladder cancer have a higher risk of cancer progression and death than do patients with Ta bladder cancer. However, this risk is much lower than that of patients with high-stage bladder cancers. Methods of identifying T1 bladder cancer patients at greatest risk for progression may significantly improve clinical management. We retrospectively evaluated two tumor suppressor genes, p53 and RB, as potential prognostic markers for progression in a cohort of 45 patients with pT1 bladder cancer. Median follow-up for these individuals was greater than 3.5 years. Of this group, 58% had altered p53 expression based on positive p53 immunostaining. Three patterns for RB nuclear protein staining were observed: absent, heterogeneous (normal), and strongly homogeneous. Progression-free survival was similar for patients with loss of RB protein expression and those with apparent overexpression of RB protein. Therefore, both staining patterns were considered abnormal. Patients with normal expression of both proteins (i.e., p53 negative and RB heterogeneously positive) had an excellent outcome, with no patient showing disease progression, whereas patients with abnormal expression of either or both proteins had a significant increase in progression (P = 0.04 and P = 0.005, respectively). These data support the stratification of T1 bladder cancer patients based on p53 and RB nuclear protein status and suggest that patients with normal protein expression for both genes can be managed conservatively, whereas patients with alterations in one and particularly both genes require more aggressive treatment.

The incidence of Helicobacter pylori in patients with interstitial cystitis.

PURPOSE: The cause of interstitial cystitis is unknown. We evaluated the incidence of Helicobacter pylori antibodies in patients with interstitial cystitis to determine whether such infection may be a causative factor. MATERIALS AND METHODS: We obtained serum samples from 23 patients with interstitial cystitis and 23 control subjects. Samples were analyzed for the presence of H. pylori IgG antibodies. RESULTS: The incidence of positive tests for H. pylori antibodies was 22% in the interstitial cystitis group and 35% in controls. CONCLUSIONS: The incidence of infection with H. pylori is not increased in interstitial cystitis, and so it is unlikely to be a causative factor.

Deoxyribonucleic acid ploidy enhances the cytological prediction of recurrent transitional cell carcinoma of the bladder.

PURPOSE: We determined whether deoxyribonucleic acid (DNA) ploidy analysis by image analysis cytometry enhances the cytological diagnosis of recurrent transitional cell carcinoma of the bladder. MATERIALS AND METHODS: A retrospective study was performed during a 5-year period to evaluate the cytological diagnosis and DNA ploidy analysis of 469 patients with previously diagnosed superficial transitional cell carcinoma. Cytological and DNA ploidy analysis was performed on 1,034 urine and bladder wash specimens, and the patients were monitored with cystoscopy and biopsies as clinically indicated. Cytology results were classified as normal, atypical, dysplastic or cancerous, and DNA ploidy was defined as normal if the diploid index was 1.2 or less, the S phase+G2M fraction was less than 21% or if there were 3% or less hyperploid cells, or abnormal if there was an increased S phase+G2M fraction, an aneuploid peak on the histogram or tetraploidy or hyperploidy was present. RESULTS: The majority of patients (85 of 88, 97%) with a cytological diagnosis of cancer had an abnormal DNA ploidy, and in 60 of 85 of these patients (71%) recurrence was diagnosed within 6 months. Only 5 of 284 specimens (2%) with normal cytology had abnormal DNA ploidy and 1 of these 5 (20%) heralded transitional cell carcinoma recurrence. However, in 145 patients with atypical cytological findings 29 (20%) with abnormal DNA ploidy had a recurrence, compared to 20 of 391 (5%) with normal DNA ploidy (p < 0.0001). Similarly, in 101 patients with dysplastic cytological findings 39 (39%) with abnormal DNA ploidy had transitional cell carcinoma recurrence compared to 4 of 25 with normal ploidy (p = 0.033). CONCLUSIONS: Abnormal DNA ploidy determined by image analysis significantly enhances the detection of bladder tumor recurrence in patients with atypical or dysplastic cytology but not in those with normal cytology or frank carcinoma on cytological findings.

CaN19 expression in benign and malignant hyperplasias of the skin and oral mucosa: evidence for a role in regenerative differentiation.

CaN19, a member of the S100 family of calcium-binding proteins, is known to be "underexpressed" in cultured breast carcinoma-derived cell lines relative to their normal counterparts. By Northern blotting, we confirm these results and find that CaN19 is also markedly "underexpressed" in several carcinoma-derived cell lines of the skin, oral mucosa, and urogenital tract. However, exceptions to the inverse correlation between CaN19 expression and malignancy have been identified, bringing into question the hypothesis that CaN19 functions as a tumor suppressor gene. Unexpectedly, CaN19 mRNA was strongly expressed in bulk specimens of basal and squamous cell carcinomas of the skin and oral cavity. However, in situ hybridization revealed only limited CaN19 expression in tumor cells themselves; the bulk of expression is localized to hyperplastic perilesional epidermis. Tumor cell expression of CaN19 was similar in primary and locally metastatic tumors, indicating that this gene is not necessarily down-regulated during tumor progression. Coordinate overexpression of CaN19 and the "hyperproliferalive" keratin K6a was observed only in tissues undergoing squamous differentiation. Taken together with other recent results from our laboratory, these findings suggest the hypothesis that CaN19 participates in an epidermal growth factor receptor-dependent pathway of regenerative squamous differentiation.

Variability of DNA analysis by image cytometry. Bladder Tumor Marker Network.

Two laboratories equipped with CAS 200 (Becton Dickinson Image Cytometry Systems, San Jose, CA) instruments participated in this study of variability of DNA analysis of bladder tumor specimens. Formalin fixed paraffin embedded specimens were disaggregated and centrifuged onto microscope slides from ten bladder tumor specimens and two specimens of normal urothelium. Sources of variability considered were Specimen, Slide, Run, Laboratory, and Error. Slides were systematically scanned and 200 cells measured followed by the operator selecting 100 nuclei with abnormal morphology. DNA index (DI) and hyperdiploid fraction (HDF) were calculated from the DNA frequency distributions. For systematic sampling, 92% of the variability was due to Specimen indicating that differences in HDF values between specimens reflect biological differences. With selective sampling, only 67% of the variability in HDF is due to Specimen differences. Other factors, Laboratory, Error, and Laboratory x Specimen interaction each accounted for approximately 10% of the variability. Similarly variability of DI with selective sampling was also higher, and less specimen dependent than systematic sampling. It is important that sampling schemes and selection criteria be carefully documented in order to control variability. Enriched (or selective) sampling for abnormal cells has the potential to increase sensitivity but specimen classification based on these measurements must depend on determination of the frequency of such cells in the total population.

Expression of mal is associated with urothelial differentiation in vitro: identification by differential display reverse-transcriptase polymerase chain reaction.

We have developed an in vitro urothelial differentiation model. In this model, differentiated urothelial cells assemble desmosomes and E-cadherin at cell-cell junctions and stratify and show antigenic and functional evidence for tight junctions. Using this urothelial differentiation model with the differential display reverse-transcriptase polymerase chain reaction (ddRT-PCR), we identified two independently isolated gene fragments that showed near identity with the reported sequence for a human cDNA clone named mal. Differential expression of mal mRNA during urothelial differentiation was confirmed by RT-PCR using two other sets of PCR primers. Furthermore, uncultured urothelial cells from tissues also express mal mRNA, as indicated by RT-PCR. Mal was originally identified in a subtracted cDNA library as a human T-cell differentiation-associated gene and was thought to be T-cell specific. Our results identify mal as a gene also expressed in urothelial cells during differentiation and demonstrate the power of ddRT-PCR for analysis of gene expression under these controlled conditions.