A holistic comparative analysis of diagnostic tests for urothelial carcinoma: a study of Cxbladder Detect, UroVysion® FISH, NMP22® and cytology based on imputation of multiple datasets.

BACKGROUND: Comparing the relative utility of diagnostic tests is challenging when available datasets are small, partial or incomplete. The analytical leverage associated with a large sample size can be gained by integrating several small datasets to enable effective and accurate across-dataset comparisons. Accordingly, we propose a methodology for a holistic comparative analysis and ranking of cancer diagnostic tests through dataset integration and imputation of missing values, using urothelial carcinoma (UC) as a case study. METHODS: Five datasets comprising samples from 939 subjects, including 89 with UC, where up to four diagnostic tests (cytology, NMP22®, UroVysion® Fluorescence In-Situ Hybridization (FISH) and Cxbladder Detect) were integrated into a single dataset containing all measured records and missing values. The tests were firstly ranked using three criteria: sensitivity, specificity and a standard variable (feature) ranking method popularly known as signal-to-noise ratio (SNR) index derived from the mean values for all subjects clinically known to have UC versus healthy subjects. Secondly, step-wise unsupervised and supervised imputation (the latter accounting for the 'clinical truth' as determined by cystoscopy) was performed using personalized modelling, k-nearest-neighbour methods, multiple logistic regression and multilayer perceptron neural networks. All imputation models were cross-validated by comparing their post-imputation predictive accuracy for UC with their pre-imputation accuracy. Finally, the post-imputation tests were re-ranked using the same three criteria. RESULTS: In both measured and imputed data sets, Cxbladder Detect ranked higher for sensitivity, and urine cytology a higher specificity, when compared with other UC tests. Cxbladder Detect consistently ranked higher than FISH and all other tests when SNR analyses were performed on measured, unsupervised and supervised imputed datasets. Supervised imputation resulted in a smaller cross-validation error. Cxbladder Detect was robust to imputation showing a 2% difference in its predictive versus clinical accuracy, outperforming FISH, NMP22 and cytology. CONCLUSION: All data analysed, pre- and post-imputation showed that Cxbladder Detect had higher SNR and outperformed all other comparator tests, including FISH. The methodology developed and validated for comparative ranking of the diagnostic tests for detecting UC, may be further applied to other cancer diagnostic datasets across population groups and multiple datasets.

A segregation index combining phenotypic (clinical characteristics) and genotypic (gene expression) biomarkers from a urine sample to triage out patients presenting with hematuria who have a low probability of urothelial carcinoma.

BACKGROUND: Hematuria can be symptomatic of urothelial carcinoma (UC) and ruling out patients with benign causes during primary evaluation is challenging. Patients with hematuria undergoing urological work-ups place significant clinical and financial burdens on healthcare systems. Current clinical evaluation involves processes that individually lack the sensitivity for accurate determination of UC. Algorithms and nomograms combining genotypic and phenotypic variables have largely focused on cancer detection and failed to improve performance. This study aimed to develop and validate a model incorporating both genotypic and phenotypic variables with high sensitivity and a high negative predictive value (NPV) combined to triage out patients with hematuria who have a low probability of having UC and may not require urological work-up. METHODS: Expression of IGFBP5, HOXA13, MDK, CDK1 and CXCR2 genes in a voided urine sample (genotypic) and age, gender, frequency of macrohematuria and smoking history (phenotypic) data were collected from 587 patients with macrohematuria. Logistic regression was used to develop predictive models for UC. A combined genotypic-phenotypic model (G + P INDEX) was compared with genotypic (G INDEX) and phenotypic (P INDEX) models. Area under receiver operating characteristic curves (AUC) defined the performance of each INDEX: high sensitivity, NPV >0.97 and a high test-negative rate was considered optimal for triaging out patients. The robustness of the G + P INDEX was tested in 40 microhematuria patients without UC. RESULTS: The G + P INDEX offered a bias-corrected AUC of 0.86 compared with 0.61 and 0.83, for the P and G INDEXs respectively. When the test-negative rate was 0.4, the G + P INDEX (sensitivity = 0.95; NPV = 0.98) offered improved performance compared with the G INDEX (sensitivity = 0.86; NPV = 0.96). 80% of patients with microhematuria who did not have UC were correctly triaged out using the G + P INDEX, therefore not requiring a full urological work-up. CONCLUSION: The adoption of G + P INDEX enables a significant change in clinical utility. G + P INDEX can be used to segregate hematuria patients with a low probability of UC with a high degree of confidence in the primary evaluation. Triaging out low-probability patients early significantly reduces the need for expensive and invasive work-ups, thereby lowering diagnosis-related adverse events and costs.

Role of heterotypic tissue interactions in deer pedicle and first antler formation-revealed via a membrane insertion approach.

Heterotypic tissue interactions play an indispensable role in organ generation and regeneration. In contrast to the classic examples of tissue interactions prevailing in the formation of tetrapod limbs or pectoral fins that can only take place when the interactive tissues are in intimate contacts, the interactions in deer antler formation are novel in that the inducer and the responder are separated by a distance of 1-2 mm. This feature offers a unique opportunity to explore the mechanism underlying tissue interactions by permitting membrane insertion between the two interactive tissues. Four experiments were conducted in this study. The results showed that the impermeable membranes inhibited antler formation. In contrast, the permeable membrane (0.45 microm in pore size) substantially slowed pedicle growth and antler initiation but did not stop them. Interestingly, the impermeable membrane/sheath only slightly retarded antler elongation. Overall, our results demonstrate that interactions between the two interactive tissues, antlerogenic tissue and the overlying skin, are indispensable for first antler initiation and are achieved through diffusible molecules rather than direct physical contact. As the heterotypic tissue interactions are only required during antler initiation but not elongation, they must be transient in nature, and thus differ from those operating in limb/fin formation that can only be sustained by continuous interactions. A system in which organ development is achieved only through transient tissue interactions must be novel, if not completely unique. Understanding this system will undoubtedly enrich the knowledge in the field of tissue interactions and organogenesis.

Nerve growth factor mRNA expression in the regenerating antler tip of red deer (Cervus elaphus).

Deer antlers are the only mammalian organs that can fully regenerate each year. During their growth phase, antlers of red deer extend at a rate of approximately 10 mm/day, a growth rate matched by the antler nerves. It was demonstrated in a previous study that extracts from deer velvet antler can promote neurite outgrowth from neural explants, suggesting a possible role for Nerve Growth Factor (NGF) in antler innervation. Here we showed using the techniques of Northern blot analysis, denervation, immunohistochemistry and in situ hybridization that NGF mRNA was expressed in the regenerating antler, principally in the smooth muscle of the arteries and arterioles of the growing antler tip. Regenerating axons followed the route of the major blood vessels, located at the interface between the dermis and the reserve mesenchyme of the antler. Denervation experiments suggested a causal relationship exists between NGF mRNA expression in arterial smooth muscle and sensory axons in the antler tip. We hypothesize that NGF expressed in the smooth muscle of the arteries and arterioles promotes and maintains antler angiogenesis and this role positions NGF ahead of axons during antler growth. As a result, NGF can serve a second role, attracting sensory axons into the antler, and thus it can provide a guidance cue to define the nerve track. This would explain the phenomenon whereby re-innervation of the regenerating antler follows vascular ingrowth. The annual growth of deer antler presents a unique opportunity to better understand the factors involved in rapid nerve regeneration.

Expression of VEGF and pleiotrophin in deer antler.

Deer antlers represent a unique model of mammalian regeneration in that they cast and fully regenerate every year. The deer antler thus provides a fascinating model of both rapid angiogenesis and chondrogenesis and the opportunity to investigate unique growth regulatory processes. One such phenomenon is the presence of vascularized cartilage in the growing antler tip-unlike other cartilage, which is typically avascular. The mechanisms by which blood vessels grow in the cartilage as well as the factors that drive antler extension at approximately 1 cm a day have been hitherto largely unknown. The aim of this study was to determine the expression of VEGF and pleiotrophin within the growing antler tip. We isolated cervine VEGF121 and VEGF165 from deer antler and found that mRNA is produced for VEGF in the precartilage and cartilage regions. By in situ hybridization, we examined whether the VEGF receptors Flt-1 and KDR are present in deer antler and found only KDR mRNA within the endothelial cells of the precartilage region. This finding is compatible with VEGF having an angiogenic effect within antler. Pleiotrophin mRNA was found in the vascular smooth muscle cells of the dermis, thus supporting a possible role in vascular growth. High levels of pleiotrophin mRNA were also detected in the precartilage region with possible implications for both angiogenesis and chondrogenesis. This is the first report of cervine angiogenic growth factors within the growing antler tip.

Vascular localization and proliferation in the growing tip of the deer antler.

The process of angiogenesis is of interest because of the significant clinical benefits associated with controlling vascular growth. Within the antler, chondrogenesis and antler elongation are occurring at the rate of 1-2 cm per day and thus blood vessels are growing at this same rapid pace. We demonstrate that the process of angiogenesis in the antler is controlled at various tissue locations. The findings clearly differentiate the spatial location of the stem cells that drive chondrogenesis from the proliferation process driving the angiogenesis. Vessels within the lateral dermis contained BrdU-positive cells, suggesting that these vessels were elongating. Within the precartilage region, proliferating vessels were detected in bundles of complex structure evenly distributed throughout this tissue layer. The support cells within these bundles of vessels were detected by staining with alpha-smooth muscle actin, while the endothelial cells were negative. Additionally, the alpha-smooth muscle actin staining was found in association with the cartilage cells of the antler. The marked proliferation of the vascular associated cells in the precartilage region identified this area as a major region of vascular growth in the antler. We propose that within the precartilage region, the most likely mechanisms to explain the observed vascular morphology are that of vascular extension of the existing vessels and intussusceptive angiogenesis or sprouting to generate the small bundles of vessels. Wiley-Liss, Inc.

Histological examination of antler regeneration in red deer (Cervus elaphus).

Annual antler renewal presents the only case of epimorphic regeneration (de novo formation of a lost appendage distal to the level of amputation) in mammals. Epimorphic regeneration is also referred to as a blastema-based process, as blastema formation at an initial stage is the prerequisite for this type of regeneration. Therefore, antler regeneration has been claimed to take place through initial blastema formation. However, this claim has never been confirmed experimentally. The present study set out to describe systematically the progression of antler regeneration in order to make a direct histological comparison with blastema formation. The results showed that wound healing over a pedicle stump was achieved by ingrowth of full-thickness pedicle skin and resulted in formation of a scar. The growth centers for the antler main beam and brow tine were formed independently at the posterior and anterior corners of the pedicle stump, respectively. The hyperplastic perichondrium surmounting each growth center was directly formed in situ by a single type of tissue: the thickening distal pedicle periosteum, which is the derivative of initial antlerogenic periosteum. Therefore, the cells residing in the pedicle periosteum can be called antler stem cells. Antler stem cells formed each growth center by initially forming bone through intramembranous ossification, then osseocartilage through transitional ossification, and finally cartilage through endochondral ossification. There was an overlap between the establishment of antler growth centers and the completion of wound healing over the pedicle stump. Overall, our results demonstrate that antler regeneration is achieved through general wound healing- and stem cell-based process, rather than through initial blastema formation. Pedicle periosteal cells directly give rise to antlers. Histogenesis of antler regeneration may recapitulate the process of initial antler generation.

Morphological observation of antler regeneration in red deer (Cervus elaphus).

Deer antler offers a unique opportunity to explore how nature solves the problem of mammalian appendage regeneration. Annual antler renewal is an example of epimorphic regeneration, which is known to take place through initial blastema formation. Detailed examination of the early process of antler regeneration, however, has thus far been lacking. Therefore, we conducted morphological observations on antler regeneration from naturally cast and artificially created pedicle/antler stumps. On the naturally cast pedicle stumps, early antler regeneration underwent four distinguishable stages (with the Chinese equivalent names): casting of previous hard antlers (oil lamp bowl), early wound healing (tiger eye), late wound healing and early regeneration (millstone), and formation of main beam and brown tine (small saddle). Overall, no cone-shaped regenerate, a common feature to blastema-based regeneration, was observed. Taken together with the examination on the sagittal plane of each regenerating stage sample, we found that there are considerable overlaps between late-stage wound healing and the establishment of posterior and anterior growth centers. Observation of antler regeneration from the artificially created stumps showed that the regeneration potential of antler remnants was significantly reduced compared with that of pedicle tissue. Interestingly, the distal portion of a pedicle stump had greater regeneration potential than the proximal region, although this differential potential may not be constitutive, but rather caused by whether or not pedicle antlerogenic tissue becomes closely associated with the enveloping skin at the cut plane. Antler formation could take place from the distal peripheral tissues of an antler/pedicle stump, without the obvious participation of the entire central bony portion. Overall, our morphological results do not support the notion that antler regeneration takes place through the initial formation of a blastema; rather, it may be a stem cell-based process.

Effect of deer velvet on sexual function in men and their partners: a double-blind, placebo-controlled study.

The use of alternative medicines and herbal remedies is an increasing trend in Western societies. For years, people have taken products made of deer velvet for their alleged beneficial effects on sexual function. There has been no scientific investigation of the effects of deer velvet powder on the sexual functioning of human males. This study investigated sexual function in men during a 12-week double-blind, placebo-controlled trial of deer velvet. Thirty-two volunteer male participants, aged 45-65 years, and their partners, were randomly assigned to either the deer velvet or placebo study group. The males took capsules containing ground deer velvet or placebo everyday for 12 weeks. Two sexual function questionnaires (the International Index of Erectile Function and the Brief Index of Sexual Function for Women) used at pre- and posttreatment assessed changes in sexual functioning in males and their partners. Blood tests at baseline, and end of study, determined levels of sex-related hormones in male participants. There were no significant differences in the sexual behavior of the men taking deer velvet compared with the men taking placebo capsules. There were no significant hormone changes from baseline to the end of the study in either group of men. We conclude that in normal males there was no advantage in taking deer velvet to enhance sexual function. All alternative health products or nutritional supplements should be subjected to randomized placebo-controlled trials to determine efficacy.

Sampling technique to discriminate the different tissue layers of growing antler tips for gene discovery.

The utilization of a deer antler model to study gene expression in tissues undergoing rapid growth has been hampered by an inability to sample the different tissue types. We report here a standardized procedure to identify different tissue types in growing antler tips and demonstrate that it can help in the classification of expressed sequence tags (ESTs). The procedure was developed using observable morphological markers within the unstained tissue at collection, and was validated by histological assessments and virtual Northern blotting. Four red deer antlers were collected at 60 days of growth and the tips (top 5 cm) were then removed. The following observable markers were identified distoproximally: the dermis (4.86 mm), the subdermal bulge (2.90 mm), the discrete columns (6.50 mm), the transition zone (a mixture of discrete and continuous columns) (3.22 mm), and the continuous columns (8.00 mm). The histological examination showed that these markers corresponded to the dermis, reserve mesenchyme, precartilage, transitional tissue from precartilage to cartilage, and cartilage, respectively. The gene expression studies revealed that these morphologically identified layers were functionally distinct tissue types and had distinct gene expression profiles. We believe that precisely defining these tissue types in growing antler tips will greatly facilitate new discoveries in this exciting field.