Muscle-derived cell injection to treat anal incontinence due to obstetric trauma: pilot study with 1 year follow-up.

OBJECTIVE: To treat anal incontinence due to obstetric external anal sphincter disruption via injection of autologous myoblast cells. DESIGN: Observational pilot study. SETTING: University hospital and district hospital PATIENTS: 10 women suffering from anal incontinence due to obstetric anal sphincter injury, refractory to conventional non-surgical therapy. INTERVENTIONS: Autologous myoblasts were cultured from a pectoralis muscle biopsy, harvested, and injected into the external anal sphincter defect using direct ultrasound guidance. MAIN OUTCOME MEASURES: Wexner incontinence score, anal squeeze pressures, and quality of life 12 months after injection. Safety and technical feasibility. RESULTS: The procedure was well tolerated and no adverse events were observed. At 12 months the Wexner incontince score had decreased by a mean of 13.7 units (95% CI, -16.3 to -11.2), anal squeeze pressures were unchanged, and overall quality of life scores improved by a median of 30 points (95% CI, 25 to 42). Anal squeeze pressures did rise significantly at 1 month and 6 months post-injection (p = 0.03). CONCLUSIONS: Injection of autologous myoblasts is safe, well tolerated, and significantly improves symptoms of anal incontinence due to obstetric anal sphincter trauma.

Ultrasound diagnosis of intra-urethral tension-free vaginal tape (TVT) position as a cause of postoperative voiding dysfunction and retropubic pain.

Intra-urethral Prolene tape erosion is a rare postoperative complication of tension-free vaginal tape (TVT) plasty. In cases reported in the literature, intra-urethral tape positioning has been diagnosed by urethroscopy as late as 3-12 months after the procedure. Introital ultrasound using a vaginal sector scanner allows for the non-invasive assessment of the position of the Prolene tape in relation to the urethra. Postoperative introital ultrasound might shorten the interval between surgery and the time of diagnosis of an intra-urethrally placed tape and thus significantly shorten the duration of symptoms. We present a patient with urethral pain syndrome and dysuria following TVT plasty. In this case, introital ultrasound was not performed until 8 months after surgery, when it demonstrated intra-urethral Prolene tape positioning as the cause of the patient's complaints. All symptoms disappeared after surgical removal of the intra-urethrally placed parts of the tape. The patient is continent, suggesting that the remaining para-urethral portions of the Prolene tape depicted sonographically ensured adequate stabilization of the mid-urethra in this case. The case report emphasizes the role of introital ultrasound in assessing Prolene tape position relative to the urethra on sagittal and transverse angulated views in the postoperative diagnostic evaluation of functional disturbances occurring after TVT plasty.

Using Activa™ TG-RM to bind beef muscles after removal of excessive seam fat between the m. longissimus thoracis and m. spinalis dorsi and heavy connective tissue from within the m. infraspinatus.

Binding beef muscles together after removing excess seam fat and heavy connective tissue was studied. Ribeye rolls and top blade roasts were fabricated from corresponding sides of 24 beef carcasses with cuts from one side serving as treated (bonded) and cuts from the other side serving as controls. For the ribeye rolls, the bonded treatment consisted of removing the kernel fat that lies between the m. spinalis dorsi and the m. longissimus thoracis. For the top blade roasts, the bonded treatment consisted of removing the heavy connective tissue sheath after the m. infraspinatus was cut open lengthwise. To bind muscles together after removal of fat or connective tissue, a dry-sprinkle mixture of Activa™ TG-RM (featuring the enzyme, transglutaminase) along with 5% sodium caseinate by weight was applied to the surfaces to be bonded (approximately 0.25% by weight was used). Steaks were cut for raw and cooked proximate analysis and energy assessment and for in-home and simulated retail case consumers studies. Bonded steaks were higher in dissectible lean, lower in energy from fat and total energy for all cuts, and higher in protein for the raw top blade, raw ribeye, and cooked ribeye steaks. Bonded ribeye steaks were lower in chemical and dissectible fat and higher in moisture. Consumers rated bonded ribeye steaks higher than control steaks for leanness and bonded top blade steaks higher for all raw appearance and cooked palatability traits. When asked to purchase bonded or control steaks from a simulated retail case, consumers purchased bonded ribeye steaks because of leanness and bonded top blade steaks because of perceived greater marbling compared to control steaks. Modifying subprimals to remove excessive seam fat and connective tissue resulted in improved physical and chemical composition of steaks and improved many visual and eating quality characteristics.

Tension-free vaginal tape operation: results of the Austrian registry.

OBJECTIVE: To assess the use of and perioperative complications associated with the tension-free vaginal tape operation with a central registry. METHODS: Fifty-five gynecology units completed questionnaires on patients undergoing the tension-free vaginal tape operation. Information was collected on patient, surgical, and postoperative data. RESULTS: A total of 2795 patients were entered. Overall, 773 patients (28%) had undergone previous surgery for incontinence or prolapse; 1640 (59%) tension-free vaginal tapes were performed as isolated operations, and 1155 (41%) were done in combination with other procedures. The median operating time for tension-free vaginal tapes alone was 30 minutes (range 10-120). Of the isolated tension-free vaginal tapes, 727 (44%) were performed with local, 711 (43%) with regional, and 193 (12%) with general anesthesia. In patients undergoing tension-free vaginal tape only, postoperative bladder drainage was obtained with intermittent catheterization in 389 (24%) patients, an indwelling urethral catheter in 1032 (63%), and a suprapubic catheter in 143 (9%). The bladder perforation rate was 2.7% overall (n = 75) and higher in patients with than in those without previous surgery (4.4% compared with 2.0%, P =.01). There were four bladder perforations (3.3%) among the 120 patients with previous colposuspension. Most patients undergoing tension-free vaginal tape only were able to void the next day (range 0 to over 64). A total of 68 patients (2.4%) required reoperation for reasons related to the tape (39 to loosen, remove, or cut the tape, or to place a suprapubic catheter, 19 for hematoma, one for bowel injury). CONCLUSION: The tension-free vaginal tape has become a frequently performed operation in Austria. There are considerable variations in clinical practice. The risk of bladder perforation was increased in patients with previous surgery. Severe complications were rare.

The Austrian tension-free vaginal tape registry.

In Austria a central registry for all TVT operations has been established in which more than 800 cases have so far been registered. The registry contains information on pertinent data on the operated patients and intra- and postoperative outcomes of the TVT surgery. No serious complications and no mortality have been registered until now.

Histone acetylation: lessons from the plant kingdom.

Post-translational acetylation of core histones is an enigmatic process. The identification of histone acetyltransferases and deacetylases as co-regulators of transcription in yeast and vertebrates has advanced our understanding of the biological role of histone acetylation and also improved our general insight into the molecular network of gene regulation. Basic features of histone acetylation in plants resemble those of other eukaryotes but there are differences, which are reflected in novel classes of histone deacetylase. Investigating histone acetylation in higher plants might reveal regulatory pathways distinct from animals, yet of essential importance for gene expression in plants.

Amide analogues of trichostatin A as inhibitors of histone deacetylase and inducers of terminal cell differentiation.

Inhibitors of histone deacetylase (HD) bear great potential as new drugs due to their ability to modulate transcription and to induce apoptosis or differentiation in cancer cells. We have described previously analogues of the complex natural HD inhibitors trapoxin B and trichostatin A with activities in the submicromolar range. Here we report structure-activity relationship analyses of further analogues of trichostatin A with respect to in vitro inhibition of maize HD-2 and their ability to induce terminal cell differentiation in Friend leukemic cells. This is the first report that shows the correlation between HD inhibitory activity and action on cancer cells on a larger series of similar compounds. Only the compounds that inhibit HD induce differentiation and/or exert antiproliferative activities in cell culture. Our studies support the use of in vitro systems as screening tools and provide structure-activity relationships that merit further investigation of this interesting target.

Pheochromocytoma and sub-clinical Cushing's syndrome during pregnancy: diagnosis, medical pre-treatment and cure by laparoscopic unilateral adrenalectomy.

The coexistence of pheochromocytoma and primary adrenal Cushing's syndrome of the same adrenal gland has rarely been reported. We describe here the case of a female patient presenting with mild Cushing's stigmata, hypertension and diabetes mellitus in whom we diagnosed a pheochromocytoma of the left adrenal gland with coexisting non-ACTH-dependent cortisol hypersecretion. While hormonal work-up was still in progress, the patient became pregnant and wanted to carry her pregnancy to full-term. A laparoscopic adrenalectomy in the 17th week of gestation was decided upon and the patient accordingly prepared for surgery by pre-treatment with phenoxybenzamine. Successful surgery--the first ever reported laparoscopic resection of a pheochromocytoma in pregnancy--without perioperative complications was performed under general anesthesia, with the patient receiving peri- and post-operative hydrocortisone substitution. Pathohistological examination revealed a pheochromocytoma with positive immunostaining for interleukin-6 (IL-6) and negative immunostaining for ACTH, vasoactive intestinal polypeptide (VIP) and cytochrome P450, and with no signs of malignancy. A paracrine stimulation of the ipsilateral adrenal cortex by IL-6 produced by the pheochromocytoma, leading to cortical hyperplasia and subclinical Cushing's syndrome, is suggested by the positive immunostaining for IL-6 and the MRI findings. Post-operatively, secondary adrenal insufficiency ensued, necessitating continuing hydrocortisone replacement over 12 months. Hypertension resolved after surgery, and diabetes after the uncomplicated vaginal delivery at term.

Virtual reality of the lower urinary tract in women.

Advances in computerized and imaging technology permit both students and doctors to depict the anatomy of the human pelvis more realistically than with previous methods. Further refinements outline fine pelvic structures, such as the nerve plexus, which may as a result be spared during major pelvic surgery, thus preserving the function of the bladder neck and urethra. Dynamic computerized tomography or magnetic resonance imaging, coupled with three-dimensional depiction of the lower urinary tract and its adjacent structures, enable visualization of the whole lower urinary tract and the pelvic floor musculature in both continent and incontinent women. In patients with a reconstructed lower urinary tract computer-assisted image processing shows the postoperatively altered topographical anatomy. This may be clinically useful for interpretation of unexpected findings with conventional imaging modalities, postoperative morbidity, and surgical planning of a lower abdominal reoperation. Examples of our own work regarding the innervation of female pelvic organs, dynamic depiction of the bladder and pelvic floor musculature during straining in normal and incontinent women, and the situation of female patients after undergoing an anterior pelvic exenteration with subsequent orthotopic neobladder procedure, are given. In addition, the data of these patients have been compiled for virtual reality endoscopy, which is useful for patient consent and for teaching residents, students and nurses.

Different types of maize histone deacetylases are distinguished by a highly complex substrate and site specificity.

Enzymes involved in histone acetylation have been identified as important transcriptional regulators. Maize embryos contain three histone deacetylase families: RPD3-type deacetylases (HD1-B), nucleolar phosphoproteins of the HD2 family, and a third form unrelated to RPD3 and HD2 (HD1-A). Here we first report on the specificity of deacetylases for core histones, acetylated histone H4 subspecies, and acetylated H4-lysine residues. HD1-A, HD1-B, and HD2 deacetylate all four core histones, although with different specificity. However, experiments with histones from different sources (hyperacetylated MELC and chicken histones) using antibodies specific for individually acetylated H4-lysine sites indicate that the enzymes recognize highly distinct acetylation patterns. Only RPD3-type deacetylase HD1-B is able to deacetylate the specific H4 di-acetylation pattern (position 12 and 5) introduced by the purified cytoplasmic histone acetyltransferase B after incubation with pure nonacetylated H4 subspecies. HD1-A and HD2 exist as phosphorylated forms. Dephosphorylation has dramatic, but opposite effects; whereas HD2 loses enzymatic activity upon dephosphorylation, HD1-A is activated with a change of specificity against acetylated H4 subspecies. The data suggest that different types of deacetylases interact with different and highly specific acetylation patterns on nucleosomes.

Randomized double-blind placebo-controlled multicenter evaluation of efficacy and dose finding of midodrine hydrochloride in women with mild to moderate stress urinary incontinence: a phase II study.

Midodrine is a potent and selective alpha1-receptor agonist and its potential to increase urethral closure pressure could be useful in the treatment of female stress incontinence. The aim of this randomized double-blind placebo-controlled multicenter study was to evaluate the efficacy and safety of midodrine for the treatment of stress urinary incontinence. The primary criterion of efficacy was the maximum urethral closure pressure at rest. Voiding diaries, symptom and incontinence questionnaires and patient/investigator global assessment were also used to evaluate its efficacy. After 4 weeks of treatment no significant changes in MUCP were found. The global assessment by the patient and investigator did indicate that patients on active treatment had a more positive assessment than the placebo group. In conclusion, midodrine did not cause significant improvements in urodynamic parameters, but there were subjective improvements in some of the patients in the treated groups. Furthermore midodrine was well tolerated.

Biochemical methods for analysis of histone deacetylases.

Specific lysine residues in the N-terminal extensions of core histones can be posttranslationally modified by acetylation of the epsilon-amino group. The dynamic equilibrium of core histone acetylation is established and maintained by histone acetyltransferases and deacetylases. Both enzymes exist as multiple enzyme forms. Histone acetyltransferases and deacetylases have recently been identified as transcriptional regulators as well as nucleolar phosphoproteins, and have therefore attracted considerable research interest. Analysis of the functional significance of histone deacetylases for nuclear processes in certain cases demands the separation and biochemical analysis of different members of the histone deacetylase families. We have characterized three different histones deacetylases in maize embryos and subsequently purified these enzymes to homogeneity. Here we describe methods for extraction, enzymatic assay, chromatographic and electrophoretic separation, and purification of deacetylases. A novel one-step procedure for large-scale preparation of individual histones and their acetylated isoforms for the analysis of substrate and site specificity of the enzymes is presented.

Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle.

BACKGROUND: On the basis of studies with animals and experience with functioning muscle transfer in plastic surgery, we have developed a surgical technique to restore detrusor function for patients with bladder acontractility in whom there is no treatment alternative. METHODS: Three patients (aged 26 years, 28 years, and 68 years) with bladder acontractility as a result of spinal-cord injury (two patients) and chronic overdistension (one patient), who required catheterisation for bladder emptying for 5 years, 2 years, and 2 years, respectively, took part in our study. The patients were treated with microneurovascular free transfer of autologous latissimus dorsi muscle to the bladder to restore detrusor function. Follow-up included clinical and urodynamic evaluation, colour doppler sonography, intravenous urography, and flow-mode computerised tomography. FINDINGS: The three patients voluntarily emptied their bladders at 16 weeks, 16 weeks, and 30 weeks after surgery, respectively. There was no need for further catheterisation throughout the follow-up period. On urodynamic assessment at 12 months after the operation bladder capacity was found to be 600 mL, 600 mL, and 650 mL, residual urinary volume 0 mL, 50 mL, 90 mL, and maximum flow rate 26 mL/s, 25 mL/s, and 18 mL/s, respectively. Activity at the transplanted latissimus dorsi was confirmed by ultrasonography and flow-mode computerised tomography. INTERPRETATION: Microneurovascular free transfer of latissimus dorsi muscle to functionally restore a deficient detrusor muscle has proved to be successful for the three patients in our study. This technique may also be an option to restore the function of other smooth-muscle organs.

Substrate and sequential site specificity of cytoplasmic histone acetyltransferases of maize and rat liver.

The cytoplasmic B-type histone acetyltransferase was purified to apparent homogeneity from maize embryos. We established a novel protocol for easy large-scale preparation of acetylated core histone species, using preparative acetic acid-urea-Triton PAGE. The pure maize histone acetyltransferase B was highly specific for histone H4 under various assay conditions, modifying H4 up to the di-acetylated isoform. Only non-acetylated H4 isoform was accepted as substrate, whereas mono-acetylated H4 could not be further acetylated. The enzyme selectively acetylated lysines 12 and 5 in a sequential manner. The same results were obtained with a partially purified cytoplasmic histone acetyltransferase of rat liver. Protein sequencing results were supported by immunological characterization of acetylated H4 subspecies with site-specific H4-acetyllysine antibodies.

[Epidermal growth factor during pregnancy- a predictor of fetal growth retardation?]. / [Epidermaler Wachstumsfaktor im Schwangerschaftsverlauf - ein Prädiktor für fetale Wachstumsretardierung?]

Epidermal growth factor (EGF) in urine was measured at 4-week intervals in 83 women referred for suspected intrauterine growth retardation (IUGR); 138 women with normal singleton pregnancies and newborns of normal weight served as controls. Of the 83 women, 30 delivered babies with weight below the 10th percentile after week 37. During pregnancy these women had shown significantly lower EGF levels than women who delivered normal-weight babies. However, due to the wide distribution of individual EGF data, no clear clinical cut-off point between normal and IUGR values could be established.

[Safety and acceptance of self application of cubic pessaries and urethral ring pessaries]. / [Sicherheit und Akzeptanz der Selbstanwendung von Würfel- und Urethraringpessaren]

OBJECTIVE: Flexible cubic and ring pessaries with a suburethral thickening are devices for the treatment of genital prolapse and urinary stress incontinence. Threads attached to the pessary enable overnight self-removal and self-application. Little is known about the safety and women's acceptance of these devices. METHODS: Eighteen women (age 36-85 years), 9 of them with failed surgery, tried this therapy (cubic pessary n = 6; ring pessary n = 12). The size of the pessary was chosen clinically. All patients were seen after a week and then monthly. RESULTS: All women showed up after 1 week. Twelve of 18 women felt comfortable with these devices at that time. During follow-up, 5/18 women wanted surgical therapy within the first 2 months, 3/18 refused the device later, 1/18 was lost to follow-up and 9/18 patients continued pessary therapy for a mean duration of 11 months. During 107 treatment months, only 2 mild complications were observed without the need to intervention (mild vaginal erosion, spotting). CONCLUSIONS: Pessary therapy is safe but has a dropout rate of approximately 50%. It can be an efficient alternative method in motivated women.

[Effect of the calcium antagonist amlodipine on non-vascular smooth muscle exemplified by the uterus]. / Die Wirkung des Kalziumantagonisten Amlodipin an nichtvaskulärer, glatter Muskulatur am Beispiel des Uterus.

The effect of amlodipine, a recently developed calciumantagonist on 21 uterine strips was investigated. Uterine activity, expressed by the area under the curve was depressed from 504 (51 to 1056) mm2 to 0 (0 to 130) 10 min after the application of amlodipine. After 20 and 60 min, the values were 0 (0 to 1310) and 0 (0 to 317) (median, 10th and 90th percentile). The decrease of uterine activity was highly significant (p < 0.0001). In summary, amlodipine exhibits a prompt and excellent relaxation on the spontaneous contractions of uterine strips.

[Intravesical electrostimulation for treatment of bladder dysfunction. Initial experiences after gynecological operations]. / Intravesikale Elektrostimulation zur Behandlung von Blasenfunktionsstörungen. Erste Erfahrungen nach gynäkologischen Operationen.

OBJECTIVE: We investigated the role of intravesical electrical stimulation in the treatment of voiding dysfunctions following major gynecologic surgery. METHODS: 19 female patients with sensory and/or motor voiding dysfunction following gynecologic operations underwent intravesical electrostimulation after failure of traditional treatments. Before and after therapy, urodynamic examinations were performed. The follow-up was 6-24 months. RESULTS: All cases of sensory bladder dysfunction were cured. Volumes of residual urine significantly decreased (mean 274 vs. 53 ml: p = 0.0003) and maximum detrusor pressure increased (mean 6 vs. 27 cm H20; p = 0.0007). An early start of therapy (within 6 weeks after surgery) resulted in a better outcome. CONCLUSIONS: Intravesical electrical stimulation was effective in the treatment of sensory and motor voiding dysfunctions following major gynecologic surgery.