Osmotic pressure test: a simple, quantitative method to assess the mechanical stability of alginate microcapsules

Implantation of microencapsulated, nonautologous cells and tissues is an effective method to deliver therapeutic proteins in vivo. Its success depends on the maintenance of the immunoisolating barrier provided by the microcapsule. Thus, one goal in the development of this technology is to create mechanically stable microcapsules. We have developed an osmotic pressure test to quantify the strength of microcapsules by exposing alginate microcapsules to a graded series of hypotonic solutions and quantifying the percentage of broken microcapsules. The test was validated by confirming the relative strengths of different types of alginate capsules, previously known from implantation in dogs to have differing mechanical stability in vivo. Thus, solid alginate microcapsules crosslinked with Ba(2+) were shown to be stronger than those crosslinked with Ca(2+), which in turn were shown to be stronger than the corresponding hollow alginate microcapsules. The incorporation of cells was demonstrated to reduce the mechanical stability of the microcapsules significantly. Hence, this test provides a simple and quantitative method for rapidly determining the strength of a large number of microcapsules. Thus, it is suitable for monitoring the mechanical stability of various types of microcapsules, predicting the performance of microcapsules in vivo, and for quality control of microcapsules during scale-up productions.

Improvement of health outcomes after continued implementation of a clinical pathway for radical nephrectomy

The clinical pathway is an important tool for outcome management. We evaluated the overall effects of the continued implementation of a clinical pathway for radical nephrectomy on the length of hospital stay, admission charges, and the quality of medical care. The data obtained from the second-year implementation (group 3) of the clinical pathway were compared with the data from the first-year implementation (group 2) and the year preceding implementation (group 1). Thirty-seven consecutive patients with renal cell carcinoma underwent radical nephrectomy in group 1, 47 in group 2, and 55 in group 3; all were enrolled in this study. The length of hospital stay, average admission charges, and 8 quality indicators were measured in these patients. We also evaluated the variances in the implementation of the clinical pathway. The mean length of stay decreased by 14.0% (P = 0.0048) in group 2, and by 15.8% (P= 0.0014) in group 3, when compared to group 1. The total admission charges significantly decreased by 19.0% (P = 0.001) in group 2, and by 27.9% (P < 0.0001) in group 3, compared to the charges for group 1. A continued decrease in charges for operation and anesthesia, laboratory, pharmacy, and others were found 2 years after implementation of the clinical pathway. Among the 8 quality indicators, 2 were continuously improved in the second-year implementation of the clinical pathway, 2 were improved significantly in the second-year implementation only, and 4 showed no significant change at all. Variances from the clinical pathway decreased significantly after continued implementation. Continued implementation of the clinical pathway for radical nephrectomy can improve a physician's practice continuously by decreasing the length of hospital stay, admission charges, and variances, and by improving quality. However, the improved results after implementation of the clinical pathway should be maintained carefully to assure good health care.

Somatic gene therapy for a neurodegenerative disease using microencapsulated recombinant cells

Neurodegenerative diseases caused by lysosomal enzyme deficiencies are catastrophic illnesses with both peripheral organ and central nervous system abnormalities. The mucopolysaccharidosis type VII mouse with beta-glucuronidase deficiency was used to develop an alternate approach to gene therapy, in which a "universal" cell line engineered to secrete the missing enzyme is implanted directly into all recipients requiring the same enzyme replacement. The cells, though nonautologous, were rendered immunologically tolerable by protection in immunoisolating microcapsules. Since the blood-brain barrier impedes the passage of large molecules such as beta-glucuronidase, encapsulated cells producing beta-glucuronidase were introduced directly into the lateral ventricles of the brain. Based on this strategy, beta-glucuronidase was delivered throughout most of the central nervous system, reversing the histological pathology and reducing the previously elevated levels of lysosomal enzymes beta-hexosaminidase and alpha-galactosidase. The effectiveness of this approach was further demonstrated with improvements in the mutant circadian rhythm behavioral abnormalities. Compared to wild-type and heterozygous mice, the mutant mice had an unstable periodicity, fragmented activity, and a sixfold reduction in wheel running activity. After treatment, the mutant behavioral abnormalities were significantly improved with a more stable periodicity and a less fragmented pattern of activity. While the overall total activity level did not increase in the treated mutants, it did not show the deterioration observed in the sham-treated as well as in the untreated mutant mice. Hence, this alternative cell-based gene therapy demonstrates biochemical, histological, and behavioral efficacy and provides a potentially cost-effective and nonviral treatment applicable to all lysosomal storage diseases with neurological deficits.

Treatment of a lysosomal storage disease, mucopolysaccharidosis VII, with microencapsulated recombinant cells

Most lysosomal enzyme deficiencies are catastrophic illnesses with no generally available treatments. We have used the beta-glucuronidase-deficient mouse model of mucopolysaccharidosis type VII (MPS VII) to develop an alternative approach to therapy. A "universal" cell line engineered to secrete the missing enzyme is implanted in all recipients requiring the same enzyme replacement. The cells, although nonautologous, are rendered immunologically tolerant by encapsulation in microcapsules that provide protection from immune mediators. Using this strategy, we injected beta-glucuronidase-secreting fibroblasts enclosed in alginate microcapsules into mutant MPS VII mice. After 24 hr, beta-glucuronidase activity was detected in the plasma, reaching 66% of physiological levels by 2 weeks postimplantation. Significant beta-glucuronidase activity was detected in liver and spleen for the duration of the 8-week experiment. Concomitantly, the intralysosomal accumulation of undegraded glycosaminoglycans was dramatically reduced in liver and spleen tissue sections and urinary glycosaminoglycan content was reduced to normal levels. Elevated secondary lysosomal enzymes beta-hexosaminidase and alpha-galactosidase were also reduced. However, implanted mutant MPS VII mice developed antibodies against the murine beta-glucuronidase, demonstrating a potential obstacle in patients with a null mutation who react against the replaced enzyme as a foreign antigen. The antibody response was transiently circumvented with a single treatment of purified anti-CD4 antibody coadministered with the microcapsules. This resulted in increased levels and duration of beta-glucuronidase delivery. Similarly, treated heterozygous mice maintained elevated levels of beta-glucuronidase and did not develop antibodies. This novel cell-based therapy demonstrates a potentially cost-effective and nonviral treatment applicable to all lysosomal storage diseases.

Improvement of medical care quality after implementation of a clinical path monitoring program for transurethral prostatectomy patients

OBJECTIVES

The purpose of this study was to determine the effect on quality of care through the implementation of a clinical path for patients receiving transurethral prostatectomy.

METHODS

We selected ten quality indicators with important clinical relevance as representative elements of the clinical path. These quality indicators were monitored during the entire hospitalization period of 100 consecutive patients who received transurethral prostatectomy. Monitoring data obtained from these patients were compared to data from 100 patients who received transurethral prostatectomy prior to implementation of the clinical path. Data was assessed to determine the relationship between quality indicators and management processes.

RESULTS

Implementation of the clinical path for transurethral prostatectomy significantly decreased the percent of patients with incomplete preoperative tests on admission day, the duration of intravenous antibiotics administration, the percent of patients who required acute pain management postoperatively, the percent of patients who received postoperative bladder irrigation with normal saline and the percent of patients who had their Foley catheter removed after postoperative day 2. Three of the quality indicators had a significant relationship with management processes and may have directly affected the total admission charges.

CONCLUSIONS

To evaluate the effect of the transurethral prostatectomy clinical path implementation on the quality of medical care, we compared ten quality indicators before and after implementation of this path. We concluded that implementation of the clinical path resulted in a statistically significant improvement in the quality of medical care.

Adrenal ganglioneuroma: report of five cases

Adrenal ganglioneuromas are rare tumors originating from the neural crest tissue of the sympathetic nervous system. The clinical presentation of most patients is asymptomatic, and most of these tumors are hormone silent. Usually the tumor is detected incidentally by abdominal imaging studies for unrelated reasons. Herein, we review our cases of adrenal ganglioneuroma over the past 20 years. All patients diagnosed with primary adrenal ganglioneuroma between 1979 and 1999 were reviewed. There were 5 cases of pathologically confirmed adrenal ganglioneuroma. All patients underwent surgical excision of the adrenal tumors. The mean age of the 5 patients (3 women and 2 men) was 27 years (range, 11 to 45 years). The average diameter of the tumor was 8.2 cm (range, 6 to 10 cm). The mean follow-up period was 33.6 months (range, 3 to 92 months). One case involved mesenteric lymph nodes. This patient had persistent hypertension following the operation, but no evidence of tumor recurrence was noted over the 7-year follow-up period. The prognosis was excellent after surgical excision in our series. Awareness of this rare entity may add to the differential diagnoses of adrenal masses preoperatively.

Canine models for human genetic neurodegenerative diseases

1. Canine models of human neurodegenerative disorders are uncommon. However, the similarity between canines and humans in body sizes and physiology provides an exceptional opportunity to use these models to study human diseases. 2. The authors will present a review on the neurological deficits that have been observed in canine models of genetic neurodegenerative diseases, and summarize the current gene therapy treatments being developed for some of these conditions.

Expression of osteopontin messenger RNA and protein in rheumatoid arthritis: effects of osteopontin on the release of collagenase 1 from articular chondrocytes and synovial fibroblasts

OBJECTIVE

Osteopontin (OPN) is an extracellular matrix protein that has been implicated in the interactions between tumor cells and host matrix, including those involved in invasion and spread of tumor cells. Because joint destruction in rheumatoid arthritis (RA) is mediated by the invasive growth of synovial tissue through its attachment to cartilage, we examined the expression of OPN in the synovia of patients with RA and the effect of OPN on the production of collagenase 1 in rheumatoid synovial fibroblasts and articular chondrocytes.

METHODS

The expression of OPN messenger RNA (mRNA) and protein in synovia from 10 RA patients was examined by in situ hybridization and immunohistochemistry. Synovial fibroblasts from RA patients and articular chondrocytes from patients without joint disease were cultured in the presence of various concentrations of OPN, and levels of collagenase 1 in the culture supernatants were measured by enzyme-linked immunosorbent assay.

RESULTS

The expression of OPN mRNA and protein was observed in 9 of 10 specimens obtained from patients with RA. OPN was expressed in the synovial lining and sublining layer and at the interface of cartilage and invading synovium. Double labeling revealed that the majority of OPN-expressing cells were positive for the fibroblast-specific enzyme prolyl 4-hydroxylase and negative for the macrophage marker CD68, while only a few, single OPN-expressing cells were positive for CD68 at sites of synovial invasion into cartilage. OPN staining was not observed in lymphocytic infiltrates or leukocyte common antigen (CD45)-positive cells. Three of 3 cultures of human articular chondrocytes secreted detectable basal amounts of collagenase, with a dose-dependent increase upon OPN stimulation, while synovial fibroblast cultures produced much lower levels of collagenase, with only 2 of 4 fibroblast cultures responding in a dose-dependent manner.

CONCLUSION

These findings suggest that OPN produced by synovial fibroblasts in the synovial lining layer and at sites of cartilage invasion not only mediates attachment of these cells to cartilage, but also contributes to matrix degradation in RA by stimulating the secretion of collagenase 1 in articular chondrocytes.

Delivery of recombinant product from subcutaneous implants of encapsulated recombinant cells in canines

Delivering recombinant therapeutic proteins from a universal microencapsulated cell line is an alternate method for gene therapy. It has proved effective in the treatment of several murine models of human genetic diseases. However, in scaling up to large animal models, intraperitoneal Implantations of these microcapsules in canines were associated with excessive Inflammatory response and rapid degradation. We now show that subcutaneous implantation of microencapsulated cells in canines is effective in delivering recombinant product systemically for extended periods, provides a surgically benign site, leads to less inflammatory response, and permits longer-term survival of microcapsules. Allogeneic MDCK cells engineered to secrete human growth hormone (hGH) were microencapsulated in alginate-poly-L-lysine-alginate and implanted subcutaneously. Systemic delivery of hGH was evident within 4 hours and peaked by day 1 after implantation in all dogs. The gradual decline of hGH in the circulation in the first 2 weeks coincided with the development of anti-hGH antibodies by day 11. The high titer persisted for more than 1 month, demonstrating indirectly the persistent delivery of hGH. Microcapsules retrieved from the subcutaneous implant maintained their structure throughout the experiment and were free of host cellular adhesions. The mechanical integrity of the subcutaneously implanted microcapsules also appeared superior to that of the intraperitoneal implant. Hence the subcutaneously implanted microcapsules required minimal surgical intervention and led to a low level of inflammatory response, and the implant survived for at least 1 month, thus demonstrating the feasibility of systemic delivery of recombinant products via subcutaneous implantation in large animals.

Galactosyl receptor, a cell surface C-type lectin of normal and tumoral prostate epithelial cells with binding affinity to endothelial cells

BACKGROUND

The mechanism of bone metastasis of prostate cancer involves the interaction of cell surface receptor(s) on cancer cells with ligand(s) on bone marrow endothelial cell surfaces. The rat galactosyl receptor gene generates two mRNA species by differential splicing: one species encodes a protein identical to the minor form of hepatocyte asialoglycoprotein receptor and displays a galactose/N-acetyl-galactosamine-recognition domain; the other encodes a protein with identical intracellular and transmembrane domains but with a different extracellular domain lacking the carbohydrate-recognition domain (CRD). Both proteins appear to coexist as a heterooligomer on the surface of normal mouse, rat, and human prostate epithelial cells and human prostate cancer cells, including the PC-3 cell line. The CRD of galactosyl receptor mediates adhesion of normal and tumoral prostate cells to the surfaces of a human bone marrow endothelial cell line. The use of inhibitors targeting the CRD would be very valuable in hindering the binding of prostate cancer cells to endothelial cells, thus decreasing the incidence of hematogenous metastasis to bone.

METHODS

Molecular biology, immunohistochemistry, flow cytometry, and a cell aggregation assay were used to determine the expression and role of the galactosyl receptor in cell adhesion.

RESULTS

Immunoblotting experiments demonstrated that each component of the heterooligomer has a mass of 54 kDa, ascribed in part to associated carbohydrates. An oligonucleotide probe showed the presence of both galactosyl receptor forms in rat prostate and testis, but not in liver, kidney, and spleen. Antibodies to the CRD and a segment of the nonhomologous extracellular domain of the galactosyl receptor blocked cell adhesion to endothelial cell monolayers.

CONCLUSIONS

The galactosyl receptor provides a valuable target for the development and use of synthetic ligands capable of disrupting endothelial cell-prostate cancer cell interaction, the first step in prostate cancer bone metastasis.

Attachment of primary neonatal rat astrocytes to vitronectin is mediated by integrins alphavbeta5 and alpha8beta1: modulation by the type 1 plasminogen activator inhibitor

Vitronectin is expressed in a cell-specific manner in the developing brain and concentrated in the brain during disease processes, such as germinal matrix hemorrhage and infarction, in which there is breakdown of the blood-brain barrier. In this study, we identified the integrin receptors that mediate attachment of primary neonatal rat astrocytes to vitronectin. Using fluorescent activated cell sorter and immunoprecipitation analyses, we established that the vitronectin receptor integrins alphavbeta5 and alpha8beta1, but not alphavbeta3, are expressed on neonatal rat astrocytes. Attachment of the neonatal astrocytes to vitronectin was inhibited (85%) in an additive manner by neutralizing anti-alphavbeta5 and anti-beta1 antibodies. Attachment to vitronectin was also inhibited in a dose-dependent manner by the type I plasminogen activator inhibitor (PAI-1), a serine protease inhibitor. Our data demonstrate that unstimulated primary neonatal rat astrocytes attach to vitronectin, utilizing integrins alphavbeta5 and alpha8beta1, and that this attachment is regulated by PAI-1.

Transforming JB6 cells exhibit enhanced integrin-mediated adhesion to osteopontin

Transformation of preneoplastic epidermal JB6 cells with tumor promoter 12-O-tetradecanoyl-phorbol-13-acetate (TPA) is an in vitro model of late-stage tumor promotion. Osteopontin (OPN) is a secreted, adhesive protein that is highly expressed in JB6 cells with TPA treatment, and its expression persists for at least 4 days, which is the time required for subsequent expression of transformed phenotype. These observations suggest that OPN may play a role in promoting JB6 cell transformation. To function in transformation of JB6 cells, OPN must bind to the surface of the JB6 cell and subsequently signal within the cell. Therefore, we investigated whether JB6 cells adhere to OPN and, if so, to which surface receptors. TPA-treated JB6 cells had significantly (P < 0.05) increased adherence to OPN compared with dimethylsulfoxide-treated control cells. Enhanced attachment of JB6 cells to OPN was also observed after treatment with another tumor promoter phorbol dibutyrate but not with nontumor promoters (phorbol and 1alpha,25-dihydroxyvitamin D(3)), suggesting that tumor promoters specifically modulate attachment to OPN. The argininylglycylaspartic acid (RGD) cell-binding region of OPN mediates attachment of TPA-treated JB6 cells because RGD, but not argininylglycylglutamic acid (RGE), peptides inhibited adherence of these cells to OPN in a dose-dependent manner. Flow cytometric analyses, blocking adhesion assay using anti-alpha(v) antibody, and co-immunoprecipitation assay all indicated that TPA-treated cells had similar levels of alpha(v) and beta(5) but decreased levels of beta(1) compared with untreated cells and that cell adhesion to OPN is most likely mediated through the alpha(v)beta(5). Furthermore, calphostin C, a specific protein kinase C (PKC) inhibitor, decreased TPA-treated JB6 cell adhesion to OPN by 50%, suggesting that TPA increased integrin affinity or avidity for OPN through a PKC-mediated pathway. Collectively, these results indicate that transforming JB6 cells adhere to OPN through its RGD sequence. The most likely OPN receptor is the alpha(v)beta(5) integrin, which increases the affinity or avidity for OPN through a PKC-dependent pathway rather than increasing the number of receptors.

Circulating leptin levels during ovulation induction: relation to adiposity and ovarian morphology

OBJECTIVE

To assess serum leptin levels based on body habitus and ovarian morphology during controlled ovarian hyperstimulation.

DESIGN

Prospective analysis.

SETTING

University IVF program.

PATIENT(S)

Women undergoing IVF-ET were divided into two groups, obese ovulatory women (n = 6; mean (+/-SD) body mass index, 30.1 +/- 0.6 kg/m(2)) and lean ovulatory women (n = 20); mean (+/- SD) body mass index 22.0 +/- 0.2 kg/m(2)). Lean women were categorized further according to whether they had polycystic-appearing ovaries (n = 8) or normal-appearing ovaries (n = 12).

INTERVENTION(S)

Controlled ovarian hyperstimulation and IVF.

MAIN OUTCOME MEASURE(S)

Serum estradiol, testosterone, and leptin.

RESULT(S)

Mean (+/- SD) leptin levels were significantly higher before and after GnRH agonist down-regulation in obese women (41.7 +/- 5.2 pg/mL and 36.1 +/- 5.8 pg/mL, respectively) compared with lean women (8.4 +/- 1.0 pg/mL and 6.9 +/- 1.1 pg/mL, respectively). Mean (+/- SD) leptin levels increased significantly in both groups (54.5 +/- 5.1 pg/mL and 11.7 +/- 1.2 pg/mL, respectively), and the mean (+/-SD) percentage increase was similar (55% +/- 18% and 54.8% +/- 17%, respectively). Mean (+/-SD) leptin levels were similar in women with polycystic-appearing and normal-appearing ovaries before controlled ovarian hyperstimulation, but increased significantly in women with polycystic-appearing ovaries afterward (14.7 +/- 1.8 pg/mL and 9.3 +/- 1.0 pg/mL, respectively).

CONCLUSION(S)

Significant increases in leptin levels occur during controlled ovarian hyperstimulation, suggesting that leptin plays a role in follicular growth and maturation. The exaggerated response in women with polycystic-appearing ovaries reflects either a greater number of recruited follicles or a predisposition of adipocytes to leptin production.

Normal ovulatory women with polycystic ovaries have hyperandrogenic pituitary-ovarian responses to gonadotropin-releasing hormone-agonist testing

Women with polycystic ovary syndrome (PCOS) have chronic anovulation and hyperandrogenism and frequently have abnormalities in their lipid profiles and insulin/insulin-like growth factor axis that increase their lifetime risk for cardiovascular disease. Normal ovulatory women may have polycystic ovaries on ultrasonography and yet lack the clinical features of PCOS. To further explore whether ovulatory women without clinical/biochemical hyperandrogenism but with polycystic appearing ovaries (ov-PAO) have subclinical features of PCOS, we prospectively characterized 26 ov-PAO women and matched them by age and body mass index to 25 ovulatory women with normal appearing ovaries (ov-NAO) and to 22 women with PCOS. After an overnight fast, all women had baseline endocrine and metabolic assessments. In addition, a subset of each group of women underwent GnRH-agonist (leuprolide acetate 1 mg s.c.) testing, ACTH stimulation, and an insulin tolerance test (ITT). At baseline, ov-PAO and ov-NAO women had similar endocrine profiles (LH, LH:FSH, androstenedione, and DHEAS). Compared with ov-NAO, 31% of ov-PAO women had reduced glucose responses after insulin (K(itt)), suggesting mild insulin resistance, and 35% had high density lipoprotein levels below 35 mg/dL, a level considered to represent significant cardiovascular risk. After GnRH-agonist, ov-PAO women had response patterns in LH, total testosterone, and 17-hydroxyprogesterone (17-OHP) that were intermediate between ov-NAO and women with PCOS. Ovarian responses were above the normal range in 30-40% of women with ov-PAO. In ov-PAO, peak responses of LH after leuprolide correlated with triglyceride levels (P < 0.05) and peak responses of 17-OHP correlated inversely with Kitt values (P < 0.05). No significant differences were noted with ACTH testing. In conclusion, occult biochemical ovarian hyperandrogenism may be uncovered using GnRH-agonist in ovulatory women with ov-PAO, while adrenal responses remain normal. Subtle metabolic abnormalities may also be prevalent.

Leiomyoma of the epididymis: case report

Herein, we report on a rare case of leiomyoma of the epididymis. The case we present involved a 55-year-old patient who had had a painless left scrotal mass for 20 years. The mass was round and elastic and measured about 2 x 2 x 2 cm. We recognized the mass as a benign tumor by scrotal ultrasonography and performed an organ salvage operation for this patient. The final pathologic diagnosis of the mass was leiomyoma. Our report includes a detailed description of the ultrasonographic characteristics of this disease as well as a review of the literature. In general, sharp acoustic shadows with central hypoechoic lesions in heterogenous parenchyma are the distinctive characteristics of leiomyoma of the epididymis. We also discuss the possibility of a testis salvage operation for this type of disease. We conclude that the ultrasonographic characteristics can serve as an important guide for the surgeon to consider an organ salvage operation in cases of a painless scrotal mass.

Gene therapy for hemophilia

Hemophilia A and B are X-linked genetic disorders caused by deficiency of the coagulation factors VIII and IX, respectively. Because of the health hazards and costs of current product replacement therapy, much effort is devoted to the development of gene therapy for these disorders. Approaches to gene therapy for the hemophilias include: ex vivo gene therapy in which cells from the intended recipients are explanted, genetically modified to secrete Factor VIII or IX, and reimplanted into the donor; in vivo gene therapy in which Factor VIII or IX encoding vectors are directly injected into the recipient; and non-autologous gene therapy in which universal cell lines engineered to secrete Factor VIII or IX are enclosed in immuno-protective devices before implantation into recipients. Research into these approaches is aided by the many murine and canine models available. While problems of achieving high and sustained levels of factor delivery, and issues related to efficacy, safety and cost are still to be resolved, progress in gene therapy for the hemophilias has been encouraging and is likely to reach human clinical trial in the foreseeable future.

Use of a medical decision support system to improve the preoperative diagnosis of prostate cancer with pelvic lymph node metastases

BACKGROUND

We evaluated the effects of a medical decision support system on the preoperative diagnosis of prostate cancer with pelvic lymph node metastases.

METHODS

The preoperative accuracy of staging prostate cancer with pelvic lymph node metastasis by the prostate cancer expert system (PCES) for 43 patients was compared to the accuracy of staging performed by 2 urological attending physicians and 5 residents, to test the validity of the PCES. The effect of PCES consultation on physicians' staging for prostate cancer with pelvic lymph node involvement was evaluated.

RESULTS

In the diagnosis of prostate cancer with pelvic lymph node metastasis, PCES was significantly more accurate than the two attending physicians alone (p = 0.042; p = 0.008). All the urological residents' diagnoses were significantly less accurate than those of the PCES. After PCES consultation, all the urological residents increased diagnostic specificity significantly. Most residents usually used PCES for consultation only after the attending physician or department asked for the results.

CONCLUSION

Owing to an increased ability for preoperative diagnosis of prostate cancer with pelvic lymph node metastasis, as supported by the PCES, some unnecessary pelvic lymphadenectomies may be avoided.

Y chromosome microdeletion in a father and his four infertile sons

Microdeletions of Yq are associated with azoospermia and severe oligozoospermia. In general, men with deletions are infertile and therefore deletions are not transmitted to sons unless in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are performed. We report an unusual family characterized by multiple members with infertility and Yq microdeletion. Complete reproductive history, semen analyses and blood samples were elicited from relevant family members. DNA preparation and quantification were performed using commercial kits. A total of 27 pairs of sequence tagged sites based primer sets specific for the Y microdeletion region loci were used for screening. Southern blots using deleted in azoospermia (DAZ) and ribosomal binding motif (RBM) cDNAs were then analysed for confirmation. The proband, his three brothers and father were all found to be deleted for DAZ but not RBM. At the time of analysis, the proband's father was azoospermic whereas his four sons were either severely oligozoospermic or azoospermic. Unlike their father, the four sons are infertile and have no offspring, except for one of them who achieved a daughter only after IVF/ICSI treatment for infertility. Microdeletions of Yq involving the DAZ gene are associated with a variable phenotypic expression that can include evidently normal fertility.

The implementation of clinical paths for six common urological procedures, and an analysis of variances

OBJECTIVE

To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths.

PATIENTS AND METHODS

The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation.

RESULTS

The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0. 01), but the mortality and readmission rate did not increase.

CONCLUSIONS

The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.

Evaluation of a decision-support system for preoperative staging of prostate cancer

The usefulness and effectiveness of a decision-support system for preoperative staging of prostate cancers (PCES) were evaluated. The study population consisted of 43 consecutive patients with the preoperative diagnosis of prostate cancer who underwent surgical operation. Results obtained using the PCES were compared with staging by four urology attending physicians and five urology residents. The effect of PCES consultation on the physicians' staging of prostate cancer was also evaluated. To confirm the usefulness of the clinical findings of prostate-specific antigen, prostate-specific antigen density, prostate volume, and abnormal Gleason score in the PCES, their receiver operating characteristic (ROC) curves for diagnosis of advanced prostate cancer were plotted. The values of the areas under the curves were 0.772, 0.800, 0.531, and 0.752. The stage of prostate cancer was correctly determined by the PCES for 38 of the 43 patients, yielding 88.4% preoperative diagnostic accuracy. The PCES was significantly more accurate than two of the attending physicians and all residents. PCES consultation improved the residents' staging accuracy to approximately that of the attending physicians. The effect of PCES consultation on the residents' staging was significantly (p < 0.001) greater than the effect on the physicians' staging. The PCES may be useful in the preoperative staging of prostate cancers, especially during residency. The system's accuracy in determining the stage of advanced prostate cancer may make it possible to avoid unneccesary surgical operations.

Reproductive outcome after sterilization reversal in women of advanced reproductive age

OBJECTIVE

Our objective was to assess the clinical outcome of tubal reversal in women of advanced reproductive age.

METHODS

A multicenter retrospective chart review of 153 patients who underwent a tubal ligation reversal was carried out. Patients were evaluated according to age. All patients had documented ovulation and a partner with a normal semen analysis by WHO criteria. Outcome measures included rates of clinical pregnancy, ectopic pregnancy, spontaneous abortion, and live birth, and the time to conception.

RESULTS

Clinical pregnancy rates were significantly lower in women > or = 40 compared to younger groups. The time to conception was significantly shorter for women < 30 compared to women > or = 35. No pregnancies occurred in women > or = 42.

CONCLUSIONS

Our data support the judicious use of sterilization reversal for infertile women with no male factor through their early forties. Women > or = 42 years should be especially counseled as to the very low success rates.

Does the use of clinical paths improve the efficiency and quality of care under the case payment system for inguinal herniorrhaphy or transurethral prostatectomy?

BACKGROUND

We evaluated the effects of implementing clinical paths for both inguinal herniorrhaphy (IH) and transurethral prostatectomy (TURP) on the efficiency and quality of medical care under the case payment system.

METHODS

Patients undergoing IH or TURP were treated using the guidelines for clinical paths under the case payment system (CPUCP). The results of treatment after implementation of CPUCP were compared with results for patients treated before implementation of CPUCP. We also compared results using eight quality indicators both before and after implementation of CPUCP.

RESULTS

The post-CPUCP length of hospital stay decreased significantly in patients who underwent either IH (p < 0.001) or TURP (p = 0.008). The post-CPUCP total admission charges decreased (p = 0.001) by 7.5% in the IH group alone. Two quality indicators in the IH group and three quality indicators in the TURP group were significantly improved after implementation of CPUCP. The percentage of patients who completed treatment without deviation as recommended by the guidelines for CPUCP was about 60% in the IH group and about 70% in the TURP group.

CONCLUSION

The results of this study indicate that the implementation of clinical paths under the case payment system for patients undergoing inguinal herniorrhaphy or transurethral prostatectomy can improve the efficiency and quality of medical care.

Encapsulation for somatic gene therapy

With the human genome project approaching its completion date of 2005, gene-based technology will play an increasingly important role in health-care delivery. Non-autologous somatic gene therapy is a novel application in which non-autologous cell lines engineered to secrete a recombinant protein are enclosed within immunoisolation devices and implanted into all patients requiring the same product for therapy. The development of this technology requires a multi-disciplinary effort towards optimization of the biomaterial used to manufacture the implantable devices and selection of the appropriate cell lines for enclosure. The efficacy of this technology is illustrated in the treatment of dwarfism and lysosomal storage disease in murine models. The potential of a safe and cost-effective gene-based delivery method should have wide applications in treating both classical genetic disorders and non-Mendelian diseases.

Review--the use of immunosuppressive agents to prevent neutralizing antibodies against a transgene product

A potential obstacle to successful gene therapy for some patients is the in vivo production of neutralizing antibodies against the recombinant therapeutic product delivered. This is a problem inherent to all gene therapy methods, regardless of the vector used to deliver the protein. This clinical situation can be mimicked in animal models by delivering a foreign protein (i.e., a human protein) to the animal to provoke anti-human protein antibody production. The efficacy of different immunosuppressive treatments to inhibit the development of neutralizing antibodies can then be investigated. The immunosuppressive agents examined here include drugs (e.g., cyclophosphamide, FK506), cytokines (e.g., interferon-gamma, interleukin-12), and monoclonal antibodies (e.g., anti-CD4, anti-gp39, CTLA4-Ig). It has been found that a high level of antibody suppression is necessary to allow prolonged delivery of a foreign protein. Immunosuppressive agents capable of this high level of suppression will be important adjuncts to prevent treatment failures in situations where patients are at risk of developing neutralizing antibodies.

Effects of implementation of 18 clinical pathways on costs and quality of care among patients undergoing urological surgery

PURPOSE

We evaluated the effects on the costs and quality of care of implementation of 18 clinical pathways for urological operations.

MATERIALS AND METHODS

From April 1997 to March 1998 patients undergoing 1 of 18 urological operations were treated according to clinical pathways. The outcomes in terms of length of hospital stay and admission charges of these patients were compared with those of patients treated between April 1996 and March 1997 before clinical pathways were implemented. We also selected 7 clinically relevant quality indicators to assess the quality of care before and after clinical pathway implementation.

RESULTS

Of the 1,784 patients undergoing urological surgery from April 1997 to March 1998, 1,382 (77.5%) were treated according to 1 of the 18 clinical pathways. Before implementation 1,279 of 1,615 patients (79.2%) underwent these procedures. The length of hospital stay decreased from 5.5 to 4.9 days (p < 0.01) and the average hospital admission charges decreased by 12.9% (p < 0.01) after implementation. Five of the quality indicators, including the rate of surgical complications, were significantly improved after pathway implementation. The hospitalization rate was not affected (1.3 before versus 0.8% after implementation, p = 0.18). Variations from the clinical pathways occurred in 543 cases (39.3%) and affected the length of hospital stay only (11.6%) or the admission charge only (12.9%) more often than both (7.8%, p < 0.01) or neither (7.0%, p < 0.01). The most common variances in these patients were patient related (30.8%).

CONCLUSIONS

Implementation of multiple clinical pathways in a urology department can improve urological practice by decreasing the length of hospital stay, admission charges and rate of surgical complications, and by improving the quality of care.